Is it time for paradigm shift in how we view mental wellbeing?

Johanna Reilly works in a GP practice for people experiencing homelessness and complex needs. She is on Twitter: @JohannaSurgeon

Campaigns to destigmatise mental health conditions have laudable aims and it is wonderful that it is now considered okay to talk about one’s feelings, but according to all metrics they do not seem to be having the desired effect.

Despite the millions of antidepressants and other medications prescribed and the many counsellors, online resources, and therapies available, most sources agree the mental health of the nation is worse, particularly among young people.1,2

A worrying trend is a rise in despair among young to middle-aged people, especially those from poorer backgrounds or who live in deprived areas. A rise in deaths of younger people due to this has been called ‘deaths of despair’.3 This links to the term ‘shit life syndrome’, which I first heard many years ago when doing general practice rotations as a medical student in the North East of England.

“… the depression and anxiety and the drug and alcohol problems started when the shipyards and mines closed.”

It was doctors’ language for an understanding that the patient was struggling but the reasons they saw their doctor were beyond what medical help could fix. Some doctors responded sympathetically to these people, others tried to minimise contact. I heard the term again more recently on a Health Foundation podcast and was surprised to hear a mental health researcher discuss her discovery of this idea and her interest in finding out what it meant.4

I was surprised because I assumed that all the great and the good, policymakers, and guideline creators knew that many patients consulting their GPs with so-called common mental disorders and often physical symptoms do so because their lives are challenging in many different ways, and they lack social supports and frameworks to integrate and put into context their challenging experiences.

Initiatives such as social prescribing and nature prescribing can be incredibly helpful to people who are struggling for connection and meaning in their day-to-day lives. Despite this I suspect most GPs have seen these fail as often as they succeed. Although the aims are laudable, I am wary, not of the workers involved who are often incredibly committed, but of what at times feels like a glib superficial response to a deep problem with economic and social roots.

Globalisation and deindustrialisation, and the break up of traditional family and social structures has resulted in wealth for some like never before but has left many people uncertain of their place and seemingly lost. In her book ‘Motherwell: A Girlhood’, Deborah Orr writes about her time growing up in the 1980s in a rapidly deindustrialising Scottish town.5 She is clear that when the factories closed, the heroin came in. It doesn’t seem to make its way into government policy papers but talking to older service users and workers from deprived post-industrial areas it’s a story I’ve heard often, the depression and anxiety and the drug and alcohol problems started when the shipyards and mines closed.

Psychologist Bruce Alexander links addiction to what he describes as ‘dislocation’, meaning a separation from traditional roots and social structures forced on people by the needs of a free market society.6 Dislocation and lack of social roles and structures are also linked to the depression, anxiety, and loneliness so often seen in a GP’s consulting room.

“… if a community doesn’t work perhaps it needs to be fixed organically from within … “

In young people it represents a crisis of huge magnitude. The pathways to a good life are often so difficult as to be almost unobtainable to most and the definition of a good life constantly changed and fluctuating according to the whims of social media. Identity and being one’s authentic self, ‘living your best life’, is seen as the highest aspiration.

While some may delight in self-actualisation there are others who find this an intolerable burden. For people with mental health struggles, the ‘right’ medication or counselling is what they believe will release them to become the person who lives their best life. Yet what I see motivate people who recover from severe difficulties and trauma is not self-esteem but the relationships they have with others.

It goes without saying that medication and hospitalisation are necessary and life saving for some people. I am concerned that by keeping everyday sadness and pain in a medical paradigm we take agency from people in managing their own lives. We prevent the broader conversations happening about what values we need in our societies and how to support these. Social prescribers are wonderful, but if a community doesn’t work perhaps it needs to be fixed organically from within — not by well-meaning professionals with a proverbial band aid.

When we use a computer scoring chart and tell a patient they have depression and need medication or even psychological therapy we locate the problem firmly in the brain of one individual. Does this prevent the wider solutions, the imagination and activism we need in the world to create a good life for all, not a privileged few?

How can we empower local communities so they make decisions that will benefit the people living there? How can we provide secure jobs for all so that people can have a settled home or raise a family? Although confidential, what happens in our consulting rooms is not separate from society but inextricably linked. Should we communicate more clearly not just the benefits of medical care but its limitations?



  1. Pitchforth J, Fahy K, Ford T, et al. Mental health and well-being trends among children and young people in the UK, 1995–2014: analysis of repeated cross-sectional national health surveys. Psychol Med 2019; 49(8): 1275–1285.
  2. Patalay P, Gage SH. Changes in millennial adolescent mental health and health-related behaviours over 10 years: a population cohort comparison study, Int J Epidemiol 2019; 48(5): 1650–1664.
  3. Allik M, Brown D, Dundas R, Leyland AH. Deaths of despair: cause-specific mortality and socioeconomic inequalities in cause-specific mortality among young men in Scotland. Int J Equity Health 2020; 19(1): 215.
  5. Orr D. Motherwell: a girlhood. London: Weidenfeld & Nicolson, 2020.
  6. Alexander BK. The globalization of addiction. Addict Res Theory 2000; 8(6): 501–526.

Featured photo by Nadine Shaabana on Unsplash.

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