The Prevalence Inflation Hypothesis
I recently wrote a post wondering if a feedback loop between reduced stigma and increased reporting might partially explain increases in mental illness among young people.
Since writing that, I’ve encountered new reporting from the New York Times about work from an Oxford team led by Lucy Foulkes and her co-author Jack L. Andrews. They’ve proposed a similar feedback loop explanation they call the prevalence inflation hypothesis.
However, in their mechanism, reductions in stigma might not only explain some of the increase in mental illness among young people but also contribute to the increase.
They’re worried the reduction in stigma leads some to overinterpret their distress as indicative of psychopathology. And that this sometimes leads people to respond to life in a more maladaptive way, and that, in turn, creates a vicious cycle that creates psychopathology.
more problematically, we propose that awareness efforts are leading some individuals to interpret and report milder forms of distress as mental health problems. We propose that this then leads some individuals to experience a genuine increase in symptoms, because labelling distress as a mental health problem can affect an individual's self-concept and behaviour in a way that is ultimately self-fulfilling. For example, interpreting low levels of anxiety as symptomatic of an anxiety disorder might lead to behavioural avoidance, which can further exacerbate anxiety symptoms. We propose that the increase in reported symptoms then drives further awareness efforts: the two processes influence each other in a cyclical, intensifying manner.
To the extent that future evidence supports the prevalence inflation hypothesis rather than just the decreased-stigma → increased-reporting feedback loop, there might be more reason to worry about reductions in stigma potentially having some iatrogenic effects. That possibility is a worrying one and can be difficult to discuss without being dismissive and belittling the very real mental health struggles people deal with. But that doesn’t mean we should ignore it.
The three stages Lucy Foulkes proposes
In the video below, Lucy Foulkes parallels the abstract above but simplifies. Here are the three stages she proposes:
Increased awareness
Overinterpretation
Self-Fulfilling Prophecy
We need to figure out just how much overinterpretation matters.
What portion of people who self-identify with a diagnostic category overinterpret their experiences?
And how large or small is the impact of the overinterpretation that happens? And to what extent are there second-order impacts through co-rumination and the amplifying mechanisms of social media more broadly?
There are many questions to answer here. I hope these questions are prioritized in the years to come.
More people getting the help they need is a good thing. And more people feeling safe to disclose how they’re feeling after hearing someone else disclose how they are feeling is yet again a good thing. That’s all progress.
But more people experiencing unnecessary suffering is obviously not a good thing. We need to disentangle how much of the reported increases in psychopathology come from increases in reporting (facilitated by reductions in stigma) vs increases in the prevalence of underlying symptoms. To further complicate things, in order to grapple with the possibility that the prevalence inflation hypothesis is at least partially supported, we also need to determine how much of the increase in underlying symptoms could partially originate in increases in reporting.
It’s a lot to hold and try to parse at once. Doing this work will be tricky. But Foulkes and Andrews detail ways to move toward getting more clarity on what’s going on here and have already started pursuing some of these avenues.
This seems like a conversation that is just starting. I hope it will continue, and that we can thread the needle of supporting people in navigating their distress while also pursuing accurate explanations of what’s leading to the increases in distress that we see.