Changes in society and young people’s mental health¹

Abstract

It is well recognized that many psychiatric disorders are strongly influenced by cultural and social factors. Foucault’s account of the modern development links together ‘madness’, psychiatry and the asylum. We pick up the story at the point Foucault left it, the mid-twentieth century, to examine cultural and social processes that are reshaping concepts, discourse and practices – the ‘social imaginary’ – around mental health, with particular reference to the apparent rise in mental health problems among the young. We conclude that this apparent rise may reflect cultural and social changes in representations of mental health. In addition, over recent decades there have been increasingly evident fractures in social solidarity, interacting with and exacerbating specific socio-political-economic-environmental stressors on younger generations, including increasing intergenerational wealth inequalities and accelerating environmental concerns.

Keywords:

• Mental health
• young people
• Foucault
• social imaginary
• post-truth
• Durkheim
• Anomie
• intergenerational wealth inequalities

Introduction

Cultural influences: Foucault’s story to the mid-twentieth century

It is well recognized that many psychiatric disorders are strongly influenced by cultural and social factors. There is rich evidence to suggest that urbanization, unemployment, overcrowding, lack of green spaces and other social determinants can contribute to psychiatric disorders. In addition, in many instances, it is the culture which determines what is normal/abnormal or deviant thereby creating disorders based on behaviours which are approved by cultures. This has been eloquently highlighted by Foucault who describes the development of a Western idea of madness (Foucault, 1961/1965). Foucault observes that in the Middle Ages madness along with all else was subject to interpretation in the Christian terms of sin and redemption, whereas in the Renaissance period, madness appeared, for example in Shakespeare and Cervantes, as excess passion, familiar to us all, typically human, interwoven with our nature, associated with an ambiguity as to who is mad and who is not, alongside an ambiguity as to who has expertise on the matter. Continuing this narrative, Foucault proposes that in the Enlightenment period during the long eighteenth century, madness crystallises as mere deficit or absence of meaning and reason. Exclusion from social epistemological space was accompanied by exclusion from geographical space into the asylums, to be managed by the mad-doctors, becoming the profession of psychiatry (Foucault 1961/1965; commentary in e.g. Still & Velody, 1992; Bolton, 2008).

How should Foucault’s story be updated?

Foucault wrote on the western idea of madness in the mid-twentieth century, seventy years ago, and as always in such time periods society has changed, so the question arises: how has Foucault’s story continued? How should we update it? Among the many changes in and around mental health since the mid-twentieth century, there was, early on, the closure of asylums and the beginnings of community care. If this were different paper, on models of mental health care delivery, from this point we would progress to a review of how community care has worked out. We are taking a different perspective, however, taking the lead from Foucault’s analysis of the socio-cultural meaning of the asylums, specifically, as the separation by exclusion of something called madness from our normal social life. This perspective is not common in the health sciences and healthcare literatures, but is found in the social sciences and humanities. For example an important distinction in human geography is between ‘space’ and ‘place’, the former, briefly, being abstract, and the latter imbued with meaning (Hubbard & Kitchin, 2011). In sociological theory the terms ‘social, or cultural, imaginary’ are used to refer to the way that cultures symbolize and behave towards themselves and others (Taylor, 2003). Our aim in this paper, in these terms, is to consider some of the profound sociocultural changes around mental health from the mid-twentieth century, implications for the cultural imaginary of merging the places of what used to be called ‘madness’, on the one hand, and ‘our mentally normal life’ on the other. The implications in broad terms are new conceptions of what used to be ‘madness’ but no longer is: rather, it becomes more familiar to us, more common, with porous and negotiable boundaries between what is and is not mentally problematic, as judged by whom, with more distributed expertise; in these ways more akin to the Renaissance ambiguity referred to above. The changes that Foucault aimed to capture occurred over a century or so – relatively large timescales, more familiar to the historian than mental health sciences and healthcare. Therefore the most that we would expect to see by way of candidate changes is an emerging picture, likely to be clearer in younger generations, engaged in them, than in older.

Apparent rise in mental health problems among the young

In the UK and in some other if not all Western democracies in the last few years there has been substantial increase in demand for child and adolescent mental health services and related services, together with some evidence of rising prevalence especially of the common mental health problems of anxiety and depression (Bor et al., 2014; Collishaw, 2015; Murray et al., 2012; Pitchforth et al., 2019). In the UK, for example, recent data from Department of Health epidemiological surveys for England (NHS Digital, 2018), show a steady increase in prevalence of mental disorders among 5–15 years old in England from 9.7% in 1999 to 10.1% in 2004 and to 11.2% in 2017, and of emotional disorders, recent increase from 4.3% in 1999 and 3.9% in 2004 to 5.8% in 2017; the 2017 survey included older adolescents and showed rates of mental disorder increasing with age from 5.5% of 2- to 4-year-olds to 16.9% among 17- to 19-year-olds, emotional disorders being the most common overall.

Rising prevalence over time is not straightforward to detect, and causes are even more speculative. The primary epidemiological data are mostly confined to descriptive epidemiology, focussing on the What, Who, Where and When, and are limited to speculation when it comes to the fifth W, the Why question in analytic or causal epidemiology. The fact is that not much is known about causes. High levels of resources in recent decades have been assigned to the two new rapidly accelerating basic sciences of genetics and neuroscience, leading to great advances, but neither of these sciences is positioned to explain increasing population prevalence of mental health problems in the young, still less increasing service demand, in the absence of knowledge of relevant population level environmental impacts interacting with the brain and possibly affecting gene expression. Rather, explanation would require a broad biopsychosocial approach (Bolton & Gillett, 2019; Engel, 1977). We consider some possible social level causes below, but first we highlight changes in social representations of mental health problems that may be implicated in increasing demand for services but which also suggest an entanglement of changes in social representations and real rises in disorder rates.

Changes in representations of mental health problems

The 1960s were a watershed moment for psychiatry and its social representation. Foucault was among many writers around that time critiquing psychiatry, psychiatrists R.D Laing and Thomas Szasz, and social scientists such as Irving Goffman, David Rosenhan and Thomas Scheff. These critiques thoroughly problematized the social role of psychiatry and its concept of mental illness and it would be fair to say that matters have not settled down since. We consider this uncertainty and flux, together with the entanglement of social representations and determination of rates of mental disorder, under four headings: Terminology, What should we call it?; Prevalence, How much of it is there?; Case definition, What is it?, and Expertise, Who can help?

Terminology: What should we call it?

There has been over the few past decades continuing reconstruction of the right words to use. A major work by Graham Thornicroft on discrimination against people with mental illness begins with a reference to ‘an active international debate on the appropriate words to use in the mental health field – in effect a terminological power struggle’ (Thornicroft, 2006, p. xv). The terminological problem is involved with efforts to reduce discrimination, social stigma and social exclusion. These efforts, we suggest, are inevitable once the sharp boundary between ‘madness’ and ‘us’, symbolized by the asylum walls, is removed. From the 1960s ‘mental illness’ gave way to ‘mental disorder’ in the diagnostic manuals then under development by the WHO and the APA. This term included a wide range of conditions, from the long-term, whole life affecting, to shorter term, and gradually there have emerged distinctions between ‘serious mental illness’ and ‘common mental health problems’, this latter clearly signifying its presence among ‘us’. The term ‘mental disorder’ is still used in the ICD and DSM diagnostic manuals, though both have long recognized the terminological problem. The ICD-10 actually puts its short definition of mental disorder under the heading ‘problems of terminology’! (World Health Organization, 1992, p. 5). These days ‘mental health problems’ is commonly used, though in non-health settings, ‘distress’ would probably be heard more frequently. Nowadays in London at least one hears young people discussing themselves or someone else having ‘mental health’ where the ‘problems’ that we older generation would have is simply left off. For want of a better word, or showing our ages, we will use ‘mental health problems’ here.

Prevalence: How much of it is there?

Another sign of contentious shifts in representations around mental health problems are ongoing professional and public debates about high prevalence estimates of mental health problems in the community. As well as not knowing what best to call this thing, we are conflicted about how much of it there is or should be or can be in us/the population. Like the terminological problems, these debates partly relate to problems of stigma and splitting. The mechanism of social exclusion of a perceived dangerous minority group presupposes that the danger really can be isolated away and is not inside ‘us’ the majority group. The really dangerous can only be in a few, over there, in another place. Some years ago one of the authors was attending a lecture by a public health official reviewing the emerging relatively high lifetime prevalence estimates of mental disorder, and saying, ‘surely we can’t all be nuts!’. Such a public exclamation was offensive then, now even more so, although the speaker did not realize this; she was speaking up, protesting, on ‘our’ behalf – though of course at ‘their’ expense. On a more academic level, though in a similar vein, and again of its time, was the book by Kutchins and Kirk (1997), Making us Crazy. DSM – the psychiatric bible and the creation of mental disorders. This kind of unwitting use of frightening, stigmatizing language is now seen less in the public domain, but the worry or indignation that common mental health disorders are being over diagnosed and especially overprescribed still has high currency (Bolton, 2013; Horwitz & Wakefield, 2012; Spence, 2013). We would distinguish between two strands in these debates. One is the concern that medications for the common mental health problems of anxiety and depression are being over-prescribed, especially for presentations that are mild and which may prove to be self-limiting, for which monitoring would be better management; the concern generally that harm outweighs good. This is a valid, practical concern and not our topic here. Our topic is rather the indignation that there really cannot be as much mental disorder about as the surveys and prescribing rates say there is, the a priori assumption that it must be rare. Would anyone mind estimates of 25% or even 100% lifetime prevalence of physical health problems? How do we know mental health problems are so much rarer? This issue is reflected in health services provision being typically so much better for physical health than for mental health, and current policy towards parity (BMA, 2020).

Case definition: What is it?

The terminological problem as to what to call it, and the epidemiological problem as to how much of it there is, beg the question what ‘it’ really is. Much has happened on this question since the 1960s. The main work has been within the diagnostic manuals, laying out clearly symptoms and syndromes for all – doctors, other professions, patients, carers and the public at large – to see. This has been a substantial contribution by the psychiatry profession to sharing – democratizing – knowledge of mental disorders. The diagnostic manuals primarily set out syndromes that we call ‘mental disorders’ but this is not yet to define the term. Definition, or conceptualization, is a theoretical task, but with practical implications, especially to help with principled decisions as to what conditions should be included or excluded from the book, with implications for access to treatment. The main theoretical work was done early on by DSM authors, resulting in a conceptualization of mental disorder in which distress and impairment of functioning are fundamental (Spitzer & Williams, 1982, with commentary in e.g. Wakefield, 1992; Bolton, 2008). Distress is intrinsic to the common mental health problems of anxiety and depression, and typically leads to impairment when it becomes intolerable or unmanageable. Since distress and impairment are personally and socially evaluated, so also are the definition and threshold of ‘caseness’. This personal and social evaluation affects both epidemiology and clinical presentations. In epidemiology, prevalence estimates depend on where the ‘clinical significance’ thresholds of distress and impairment are set (Frances, 1998). Attendance at the clinic depends on personal and social evaluations distress and impairment, along with belief that they should be and are remediable by health expertise, as opposed to being e.g. part of normal life.

Expertise: Who can help?

Threading though and interacting with these above issues is the social representation of who has the expertise in mental health. Foucault left the story mid-twentieth century with the mad-doctors become psychiatrists managing madness somewhere else, in the asylums, society at large having set this up so as to have nothing to do with it. With an important caveat, however, that Freud started a reverse movement, listening to ‘madness’ (Foucault, 1961/1965, pp. 277–78). This new strand has escalated ever since, increasingly since the mid-twentieth century, with many new theoretical models and professions of psychotherapy and counselling, delivered inside and outside health-settings, and increasingly on-line including self-help apps.

Problematizing real vs. apparent rate rises

In the traditional epidemiology of infectious diseases and some non-communicable conditions there is a clear distinction between a real rise in prevalence, detectable by laboratory biological testing, and apparent rises attributable to such as better self- or services-detection, better access to service provision and more help-seeking. This distinction between real and apparent rate rises is problematized, however, in the absence of a laboratory test, for health conditions in which subjective experience, distress or pain, is fundamental. This point is elaborated by the considerations so far in this section. We have reviewed ways in which representations of common mental health problems – psychiatric, social and personal – have been changing over the past few decades, affecting public discourse, epidemiological estimates, clinical presentations, help-offering and help-seeking. And it is a plausible hypothesis that such processes are likely to be most affecting younger generations for whom they are ‘normal’.

Socio-technological changes

We include this section because of massive acceleration in use of social media and speculations in public and academic domains about adverse effects it may be having on the well-being of the young. As to evidence, a recent review of reviews by Orben (2020) comes to cautious conclusions: most studies are methodologically limited; there may be negative effects, but small; direction of causation is not clear; and there is little understanding of the relevant individual differences. A related though distinct point is that new technology embraced by the young can give rise to new psychiatric presentations, particularly internet gaming addiction (Petry & O’Brien, 2013).

Sociocultural group fractures, anomie, post-truth

Social cohesion and anomie

In this section we broaden the picture to consider disruptions in social cohesion and solidarity that may be raising anxiety and depression. The general proposal that social cohesion is a protective factor for individual level of stress is common in current social epidemiological theory (Marmot, 2010), but has a history since the beginning of social science in Emile Durkheim’s work on social factors in suicide (Durkheim, 1897/1952; Parsons, 1937). Hypothesized protective mechanisms involve stability in basic social categories and practices that enable an individual to have enough certainty and sense of control, agency or autonomy, over salient outcomes. Risk mechanisms conversely: instability leads to uncertainty and perceived lack of control, raising risk of anxiety and depression. Durkheim proposed a typology of social organization, but also theorized the penetration of these social factors into aspects of individual personality, relevant specifically to suicide and related conditions of depression and anxiety. Our main interest here is Durkheim’s Anomie type, which etymologically refers to absence of laws or norms. Social Anomie is a type of social organization characterized by breakdowns of social regulation and group control, implying a problematic, stressful ‘freedom’ for the individual (Durkheim, 1897/1952, p. 241f.; Parsons, 1937, p. 334f.; Wray et al., 2011, p. 521.)

Culture conflicts and post-truth

The last few decades have been increasingly characterized by fractures in social cohesion and associated stress, referred to in many ways in the public sphere, such as culture wars, mainly between social conservativism and social liberalism (Boghossian, 2019; Hunter, 1991; Tan & Mura, 2019), post-truth (Davis, 2017; Farkas & Schou, 2019), Age of Anger (Mishra, 2017), Age of Rage (Robertson, 2018) and Age of Anxiety (Lavin, 2019).

Cultural conflicts between socially conservative and socially liberal groupings have increasingly affected politics; for critical discussion of the socio-demographics of emerging political alignments see e.g. McCall and Orloff (2017) and Ford and Jennings (2020). In the midst of these conflicts, ‘post-truth’ has appeared. The term is used more among the socially liberal, to refer to propagation of claims that are obviously untrue or which fly in the face of scientific evidence and expertise, especially to such claims made by politicians with a social conservative constituency. One striking feature of this rupture is that it is epistemological, that is to say, to do with truth, facts, objectivity, evidence and reasonable belief. When Durkheim spoke about anomie, times of absence of social norms, the norms he emphasized were moral (Durkheim, 1897/1952, p. 241f.; Parsons, 1937, p. 336). Social fracture over epistemological norms appears as something new, especially offensive and worrying to political liberalism, which relies on shared norms of rationality in public and political discourse (Rawls, 1997). However, the epistemological problems probably cut both ways. Social liberalism has always strived for inclusivity, in successive emancipatory movements, most recently and currently concerning sexual and gender identity. These social emancipatory movements always involve challenging the prevailing socially conservative view of facts about human nature and what is reasonable or unreasonable to say about it.

Cultural conflicts of the kinds outlined above are both long-standing and evolving. However, it might be true to say that they are now more in-your-public-face. One reason applies particularly in the liberal democracies, which have seen increasing vote-share and public profile of political populism. Another reason is social media, which multiplies and amplifies a continuous stream of voices, opinions, facts, theories and conspiracies of all more or less conflicting sorts.

The conflictual cultural processes referred to above are large-scale, highly complex, hard to research, and require caution in theory. We intend to do no more than raise the question: what is it like to grow up in such a world, as a child or young teenager, and what is it like in such a world, for older adolescents and young adults, to try to imagine and work towards your future goals. Hypotheses worth considering are that they may struggle with the questions: Who and what are they to believe? How are they to know what is going to happen and how plan their future, ends and means, accordingly? To the extent that there are disagreements over fundamental matters between vocal and active groups, both influencing events, both ‘sides’ are likely to find what is going on hard to understand, unpredictable and therefore stressful.

Durkheim supposed that anomie arose in times of substantial social changes, and discusses changes in the economic cycle in this connection (Durkheim, 1897/1952, p. 241f.; Parsons, 1937, p. 334f.). We consider this next especially as it is now affecting the young.

Specific stress factors affecting the young

In previous sections we have highlighted changes in social representations of mental health, affecting self-representation and experience that may be contributing to rise in mental health presentations among the young. In this section we consider the conceptually less complicated hypothesis that the young are subject to increasing stressors. We focus on social stressors, setting others aside as out of scope, for example possible raised risk to mental health attributable to increasing use of non-prescribed drugs (Bae & Kerr, 2020; Degenhardt et al., 2016). We consider two social stress factors differentially affecting the young that may be contributing to rising anxiety and depression: increasing intergenerational wealth inequalities, and widespread concerns about climate change.

Increasing intergenerational wealth inequalities

Linkage between economic hardship and poor health has long been known, and underpins the social gradient in health and health inequalities (Marmot Review Team, 2020; World Health Organization, 2017). The main hypothesized aetiological pathway (for many non-communicable diseases) implicates chronic stress, perceived lack of control over salient outcomes, which accumulates in less resourced populations (Black, 2002; Epel et al., 2018; Marmot, 2010). Considered over time (rather than cross-sectionally), the implication is that economic downturn leads to poorer health. There is evidence that the economic consequences of the 2008 financial crash had negative impacts on population mental health (World Health Organization, 2011). Increasing poverty and negative impacts on parents in turn would raise risk of negative impacts on children, for example increasing risk of suicide (Hoffmann et al. 2020) and adverse child experiences (Merrick et al. 2019).

As well as negative impacts of economic downturns on the mental health of parents and children already experiencing economic adversity, it is likely that also those not yet affected may be stressed because of severe worry about the future. Given adverse economic trends, in the UK for example (Sowels, 2018), the young have expectations of less stable accommodation, and less job and financial security, compared with their parents. They are less likely than their parents to own property or to be in stable social housing, less likely to have well paid graduate professional or manual skilled work, more likely to work zero-hour contracts with little job security (instanced at the time of writing by losing work without economic protection by restrictions during the Covid-19 epidemic). Our assumption here is that the young are only too aware of being on the wrong side of increasing wealth inequalities, relative to expectations – relative to and hence independent of socio-economic class – thereby generating distress and stress. The mechanisms are probably different at different ages, involving more or less parental transmission. Parents are well aware of the challenges in their children’s future and anxious for them to get into the right schools and get good exam results and qualifications – anxiety which the children are able to recognize. Or, another kind of pathway, the parents see decreasing hope of employment or stable work locally, and their children and adolescents pick that up.

We hypothesize that anxiety arising from expectations of downwards economic resources would apply to all socio-economic classes but would be sensitive to differences in groups with downward/neutral/upward expectations. For example, young people in families with the highest levels of socio-economic resources, associated with access to private education, high reputation university education, professional networks and accumulated family wealth, might expect to retain their family of origin socio-economic status, while everyone else has expectations of lower status. This hypothesis is consistent with UK 2017 data on rates of mental disorder in 5- to 19-year-olds, showing an expected overall correlation with income levels, but also showing that the sharpest increase in rates is between the highest and the second highest of five income levels, as follows: 4.1%, 6.3%, 8.3%, 9.7%, 9.0% (NHS Digital, 2018). As another example, individuals might be sensitive to expected trajectories varying by ethnic/cultural groupings. For example, children and young people in some immigrant groups, especially if well acculturated (Berry & Hou, 2016), might have expectations of upwards social mobility, being aspirational rather than anxious about their future. This hypothesis is consistent with the same UK 2017 data showing variation between ethnic groups, with much higher rates in White British children (14.9%) compared with those who were Black/Black British (5.6%) or Asian/Asian British (5.2%).

Climate change and other concerns

There is no doubt that various geopolitical determinants affect mental health of individuals and communities. Amnesty International (2019) commissioned a poll from Ipsos MORI who surveyed nearly 11,000 people aged 18–25, in Generation Z, in 22 countries across six continents, asked to choose up to five most important issues, globally and nationally, from a list of 23. Globally, the most commonly cited issue was climate change, cited by 41%, prompting the comment by Kumi Naidoo, Amnesty’s outgoing secretary general: ‘For young people, the climate crisis is one of the defining challenges of their age’ (Amnesty International, 2019). On the same poll, pollution was ranked second at 36% for global concerns, and terrorism third at 31%, while at the national level, corruption, pollution, economic instability and income inequality came out as the top four concerns, with climate change fifth. The young have a lot to worry about.

Conclusions

Since the mid-twentieth century, practically and symbolically marked by the closing of the asylums, concepts, discourse and practices around mental health have been adjusting to ‘mental health problems’ becoming in and among ‘us’. This has involved uncertainty and controversy in terminology, prevalence, case definition and distribution of expertise. This is the social context in which there has been a rise in mental health problems and demand for services among the young. In addition, over recent decades there have been increasingly evident fractures in social solidarity, interacting with and exacerbating specific socio-political-economic-environmental stressors on younger generations, including increasing intergenerational wealth inequalities, and accelerating worries about climate change.

Disclosure statement

No potential conflict of interest was reported by the author(s).