Your "alternative explanation for the increases in the prevalence of measured psychopathology among youth":
1. Decrease in stigma leads to an increase in reporting
2. Increases in reporting lead to a further decrease in stigma
3. Repeat steps 1 and 2 over and over
could just as likely be:
1. Increase in social status for reporting mental health issues
2. Increases in status leads to a further increase in reporting
3. Repeat steps 1 and 2 over and over
Haidt addresses this in "The Anxious Generation" when he observes that mental health ER visits have soared even while mental health hospitalizations have remained flat.
Thanks for reading my post, Ben. I appreciate you taking the time, and engaging with it.
I think there’s an implicit (social) in front of stigma. Although some of it is probably internal too. So maybe social stigma and social status are two different ways of describing evaluations of the social impact. I.e., could phrase it as reductions in stigma around endorsing mental health problems or reductions in the negative social status impact of mental health problems.
To your point about the discrepancy between ER visits and hospitalizations - as best as I can tell that’s not a discrepancy that Haidt points to in his book. But if there’s a passage from his work you’ve found where he indicates otherwise, please do let me know.
From what I’ve gathered, I think this is what he had to say on that front, from pp.30-31, regarding checking whether behaviours are changing vs thoughts/feelings alone:
“A good way to do that is to look at changes in measures not self-reported by teens. For example, many studies chart changes in the number of adolescents brought in for emergency psychiatric care, or admitted to hospitals each year because they deliberately harmed themselves. This can either be in a suicide attempt, commonly done by overdosing on medications, or in what is called nonsuicidal self-injury (NSSI), often done by cutting oneself without the intent to die. … The rapid increases in rates of self-harm and suicide, in conjunction with the self-report studies showing increases in anxiety and depression, offer a strong rebuttal to those who were skeptical about the existence of a mental health crisis. I am not saying that none of the increase in anxiety and depression is due to a greater willingness to report these conditions (which is a good thing) or due to some adolescents who began to pathologize normal anxiety and discomfort (which is not a good thing). But the pairing of self-reported suffering with behavioral changes tells us that something big changed in the lives of adolescents in the early 2010s, perhaps beginning in the late 2000s.”
As it happens, though, based on Corridor-Waldron & Currie (2023) I do wonder if there might be more to the story about the relationship between ER visits for suicide ideation vs suicide attempts, and am working through the data on that front. But so far my sense is that there is no denying that even though the increase in suicide ideation among young people is much higher than the increase in suicidal behaviours, there has been an increase in suicidal behaviours as well.
You are right that the discrepancy between ER visits and hospitalizations is not in “The Anxious Generation.” What I was remembering was Haidt’s blog responding to critics of the book “The Girls Are Not Alright: Responses to Three Claims that the Youth Mental Health Crisis Is Exaggerated.” https://www.afterbabel.com/p/the-girls-are-not-alright-responses
In the section “Challenge #1: The girls are alright: Rates of self-harm are rising primarily because there’s less stigma associated with going to the emergency room,” Haidt argues, “Some have pointed out that emergency department visits for self-harm may also be influenced by changing norms and willingness to seek help, making these data yet another unreliable gauge for true changes in a population's mental health. However, I believe that rates of hospitalizations can help us distinguish the signal from the noise and more reliably indicate whether the mental health of a population is getting worse.”
He goes on to make the point that hospitalizations are a better measure of actual mental health issues: “Being hospitalized is much rarer than visiting the emergency department, and it requires clearance by their medical provider (i.e., kids are not making the choice themselves). Most kids who go to the emergency department are not hospitalized, as hospitalization is reserved for the most severe cases.”
“So, while the initial reason adolescent girls are showing up at the ED at higher rates could plausibly be related to decreased stigma, it does not explain why they would be actually admitted more often unless they were, in fact, actually experiencing severe symptoms.”
When thinking through the multivariate problem of the causes of reported mental health issues, there are several potential factors I am weighing:
Stigma – Mental health disorders that previously were unreported are now reported due to reduced stigma. I believe this was the framework in your original post. This could lead to both increased ER visits and hospitalizations.
Social reward – Haidt is suggesting that social status is causing individuals to report mental health issues that don’t exist. This was my suggested alternative framework in my previous comment: this could lead to both increased ER visits and hospitalizations. Both Haidt and Abigail Shrier in “Bad Therapy” have argued that this is a significant factor.
Psychosocial stressors – I believe this is the mechanism that Haidt weighs the heaviest in increased reporting of mental health issues. Smartphones and social media fundamentally change the social development of children, leading to increased loneliness, depression, and suicidal ideation.
Environmental stressors – Haidt argues that external conditions, economic hardship, and natural disasters are not factors in driving the increase in reported mental health problems.
Changes in coding – You mention Corredor-Waldron & Currie (2023), which I believe is Corredor-Waldron, Adriana, and Janet Currie (2024). They suggest that changes in the coding of suicidal ideation as a secondary diagnosis was a primary factor in increasing reported suicidal behaviors. This strikes me as believable. It will be interesting to see if it can be replicated elsewhere.
I applaud you for plunging in and seeing how the data can help us sort out the impact of these various factors.
Foulkes, Lucy, and Jack L. Andrews. 2023. "Are mental health awareness efforts contributing to the rise in reported mental health problems? A call to test the prevalence inflation hypothesis." New Ideas in Psychology 69: 101010. https://doi.org/10.1016/j.newideapsych.2023.101010.
Key conclusions:
1. Mental health awareness efforts are contributing to reported increases in mental health problems through improved recognition and overinterpretation.
• Improved recognition is a beneficial outcome leading to more accurate reporting of previously under-recognized symptoms.
• Overinterpretation is problematic, leading to misinterpretation of milder distress as mental health problems.
• Overinterpretation can become a self-fulfilling prophecy, genuinely increasing symptoms by affecting self-concept and behavior. Example: interpreting mild anxiety as an anxiety disorder leads to avoidance that exacerbates anxiety.
2. The relationship between prevalence inflation and mental health awareness efforts is cyclical and intensifying.
• As prevalence of mental health problems increases, organizations respond with more awareness efforts.
• But the awareness efforts themselves may lead to further increases in prevalence through the mechanisms of improved recognition and overinterpretation.
• Prevalence and awareness efforts influence each other in an escalating cycle.
3. Some existing evidence supports the prevalence inflation hypothesis.
• RCTs found psychological debriefing increased PTSD symptoms and CBT school interventions increased internalizing symptoms, possibly by heightening awareness and expectation of symptoms.
• Qualitative studies indicate some individuals report awareness efforts made them feel worse by increasing insight into difficulties.
• Experiments show telling people they are experiencing symptoms leads to subsequently reporting more symptoms.
If bipolar clinical diagnosis requires a major depressive episode, and depression is linked to social media usage, it seems that bipolar wouldn't be a good control
Thanks for reading this and commenting, David. I appreciate it!
I see what you're getting at. I'll have to think about it some more. I wonder whether the portion of bipolar diagnoses that overlaps with depression would explain away most of that increase.
It also raises the question of why social media would increase mania and hypomania.
Your "alternative explanation for the increases in the prevalence of measured psychopathology among youth":
1. Decrease in stigma leads to an increase in reporting
2. Increases in reporting lead to a further decrease in stigma
3. Repeat steps 1 and 2 over and over
could just as likely be:
1. Increase in social status for reporting mental health issues
2. Increases in status leads to a further increase in reporting
3. Repeat steps 1 and 2 over and over
Haidt addresses this in "The Anxious Generation" when he observes that mental health ER visits have soared even while mental health hospitalizations have remained flat.
Thanks for reading my post, Ben. I appreciate you taking the time, and engaging with it.
I think there’s an implicit (social) in front of stigma. Although some of it is probably internal too. So maybe social stigma and social status are two different ways of describing evaluations of the social impact. I.e., could phrase it as reductions in stigma around endorsing mental health problems or reductions in the negative social status impact of mental health problems.
To your point about the discrepancy between ER visits and hospitalizations - as best as I can tell that’s not a discrepancy that Haidt points to in his book. But if there’s a passage from his work you’ve found where he indicates otherwise, please do let me know.
From what I’ve gathered, I think this is what he had to say on that front, from pp.30-31, regarding checking whether behaviours are changing vs thoughts/feelings alone:
“A good way to do that is to look at changes in measures not self-reported by teens. For example, many studies chart changes in the number of adolescents brought in for emergency psychiatric care, or admitted to hospitals each year because they deliberately harmed themselves. This can either be in a suicide attempt, commonly done by overdosing on medications, or in what is called nonsuicidal self-injury (NSSI), often done by cutting oneself without the intent to die. … The rapid increases in rates of self-harm and suicide, in conjunction with the self-report studies showing increases in anxiety and depression, offer a strong rebuttal to those who were skeptical about the existence of a mental health crisis. I am not saying that none of the increase in anxiety and depression is due to a greater willingness to report these conditions (which is a good thing) or due to some adolescents who began to pathologize normal anxiety and discomfort (which is not a good thing). But the pairing of self-reported suffering with behavioral changes tells us that something big changed in the lives of adolescents in the early 2010s, perhaps beginning in the late 2000s.”
As it happens, though, based on Corridor-Waldron & Currie (2023) I do wonder if there might be more to the story about the relationship between ER visits for suicide ideation vs suicide attempts, and am working through the data on that front. But so far my sense is that there is no denying that even though the increase in suicide ideation among young people is much higher than the increase in suicidal behaviours, there has been an increase in suicidal behaviours as well.
You are right that the discrepancy between ER visits and hospitalizations is not in “The Anxious Generation.” What I was remembering was Haidt’s blog responding to critics of the book “The Girls Are Not Alright: Responses to Three Claims that the Youth Mental Health Crisis Is Exaggerated.” https://www.afterbabel.com/p/the-girls-are-not-alright-responses
In the section “Challenge #1: The girls are alright: Rates of self-harm are rising primarily because there’s less stigma associated with going to the emergency room,” Haidt argues, “Some have pointed out that emergency department visits for self-harm may also be influenced by changing norms and willingness to seek help, making these data yet another unreliable gauge for true changes in a population's mental health. However, I believe that rates of hospitalizations can help us distinguish the signal from the noise and more reliably indicate whether the mental health of a population is getting worse.”
He goes on to make the point that hospitalizations are a better measure of actual mental health issues: “Being hospitalized is much rarer than visiting the emergency department, and it requires clearance by their medical provider (i.e., kids are not making the choice themselves). Most kids who go to the emergency department are not hospitalized, as hospitalization is reserved for the most severe cases.”
“So, while the initial reason adolescent girls are showing up at the ED at higher rates could plausibly be related to decreased stigma, it does not explain why they would be actually admitted more often unless they were, in fact, actually experiencing severe symptoms.”
When thinking through the multivariate problem of the causes of reported mental health issues, there are several potential factors I am weighing:
Stigma – Mental health disorders that previously were unreported are now reported due to reduced stigma. I believe this was the framework in your original post. This could lead to both increased ER visits and hospitalizations.
Social reward – Haidt is suggesting that social status is causing individuals to report mental health issues that don’t exist. This was my suggested alternative framework in my previous comment: this could lead to both increased ER visits and hospitalizations. Both Haidt and Abigail Shrier in “Bad Therapy” have argued that this is a significant factor.
Psychosocial stressors – I believe this is the mechanism that Haidt weighs the heaviest in increased reporting of mental health issues. Smartphones and social media fundamentally change the social development of children, leading to increased loneliness, depression, and suicidal ideation.
Environmental stressors – Haidt argues that external conditions, economic hardship, and natural disasters are not factors in driving the increase in reported mental health problems.
Changes in coding – You mention Corredor-Waldron & Currie (2023), which I believe is Corredor-Waldron, Adriana, and Janet Currie (2024). They suggest that changes in the coding of suicidal ideation as a secondary diagnosis was a primary factor in increasing reported suicidal behaviors. This strikes me as believable. It will be interesting to see if it can be replicated elsewhere.
I applaud you for plunging in and seeing how the data can help us sort out the impact of these various factors.
I also recommend:
Foulkes, Lucy, and Jack L. Andrews. 2023. "Are mental health awareness efforts contributing to the rise in reported mental health problems? A call to test the prevalence inflation hypothesis." New Ideas in Psychology 69: 101010. https://doi.org/10.1016/j.newideapsych.2023.101010.
Key conclusions:
1. Mental health awareness efforts are contributing to reported increases in mental health problems through improved recognition and overinterpretation.
• Improved recognition is a beneficial outcome leading to more accurate reporting of previously under-recognized symptoms.
• Overinterpretation is problematic, leading to misinterpretation of milder distress as mental health problems.
• Overinterpretation can become a self-fulfilling prophecy, genuinely increasing symptoms by affecting self-concept and behavior. Example: interpreting mild anxiety as an anxiety disorder leads to avoidance that exacerbates anxiety.
2. The relationship between prevalence inflation and mental health awareness efforts is cyclical and intensifying.
• As prevalence of mental health problems increases, organizations respond with more awareness efforts.
• But the awareness efforts themselves may lead to further increases in prevalence through the mechanisms of improved recognition and overinterpretation.
• Prevalence and awareness efforts influence each other in an escalating cycle.
3. Some existing evidence supports the prevalence inflation hypothesis.
• RCTs found psychological debriefing increased PTSD symptoms and CBT school interventions increased internalizing symptoms, possibly by heightening awareness and expectation of symptoms.
• Qualitative studies indicate some individuals report awareness efforts made them feel worse by increasing insight into difficulties.
• Experiments show telling people they are experiencing symptoms leads to subsequently reporting more symptoms.
If bipolar clinical diagnosis requires a major depressive episode, and depression is linked to social media usage, it seems that bipolar wouldn't be a good control
Thanks for reading this and commenting, David. I appreciate it!
I see what you're getting at. I'll have to think about it some more. I wonder whether the portion of bipolar diagnoses that overlaps with depression would explain away most of that increase.
It also raises the question of why social media would increase mania and hypomania.