Many people will be very concerned as they wait to hear how the Government’s proposed £5 billion benefits cuts might affect them. Losing financial support that you have come to rely on can be deeply worrying.

The proposed changes are a response to the rapidly increasing cost of welfare. The Centre for Social Justice estimates this is currently £81 billion each year and rising. Much of the recent increase has been due to mental health claims. For example, young people seem to have embraced the idea of ADHD as an explanation for their difficulties. The rate of this diagnosis has increased by 18% in each of the last four years. Those who argue against the cuts say that this rapid increase in diagnoses is simply due to increased awareness of mental health difficulties.  

As another example the BBC recently reported that there are about a million people in the UK said to have bipolar disorder at an estimated cost of 9.6 billion. Many experts are saying that this is the tip of the iceberg and that many more people remain undiagnosed and that services should be improved.

But could there be another largely unrecognised but more fundamental reason for these increases in various mental health diagnoses?

For many years politicians and commentators have argued that mental health should be regarded in a similar way to physical health. There has been little challenge to this far-reaching idea.

However, while it is not possible to draw a hard and fast line between physical and mental health difficulties, there is a vital difference. That difference depends on how we think about what it is to be human. Are we simply clever animals? Animals nevertheless; biological machines simply pushed and pulled by our fundamental chemistry and the events that happen to us. If this were the case, perhaps, we should see mental and physical health as equivalent.

While we might think like this in some areas of our lives, I suspect few of us go along with this completely. The reason we don’t is that we know from our lived experience that how we think makes a difference. The fact is that none of us can avoid thinking, even if at times we would rather avoid the effort and pain involved.  

We cannot make sense of the world and our situation without thinking. We cannot make plans, have hopes and dreams, make choices of how to live, or what to believe in, who to love and how to love them. The list of what we do when we think is endless. When we do these things, we are making choices that only we can make. By these choices we animate ourselves; we make and remake ourselves; we continuously create our unique individuality and shape our experiences. This is what makes mental health fundamentally different from physical health. (Having said this, it is of course true, how we think about and react to our physical illnesses makes an important difference to how we experience them.)

When we recognise this, we must admit we are active agents managing our lives as best we can. However, our culture does little to encourage us to appreciate the power of our thinking. It is the case that our current ideas about mental health make it harder for us to have this appreciation. If we are told we HAVE a mental health condition and that this condition is the cause of our distress we are likely to conclude there is little we can do to understand how our thoughts and behaviour have contributed to our difficulties. Instead, rather than seeing ourselves as active agents we become patients who simply need to take our place on a waiting list.

Seeing physical and mental health as equivalent has been a cultural disaster. But what is this to do with the GPs’ Dilemma in the title of this piece?

GPs are the primary gatekeepers for access to the benefits system. They decide who gets a fit note and who is referred on to the mental health services.

The GP’s task is next to impossible. Few become GPs without wanting to help people. They want to offer solutions to their patient’s difficulties. However, their time is very limited. On average they have 10 minutes for a consultation. They have to rely on a patient’s self-description of their difficulties. How patients present their case is vital. The fact that every GP surgery I have visited has notices stating that abusive behaviour will not be accepted suggests that patients can sometimes be assertive in seeking solutions for their problems. Many patients expect prescriptions. 

Some 6 million people in the UK take antidepressants. Most of these are prescribed by GPs. However, research by the Centre for Social Justice into GP attitudes towards antidepressants has revealed interesting results. It suggests they face a dilemma. They sit at a critical juncture of the welfare system; they want to help but due to various pressures they offer a solution they don’t fully believe in.

The report found, “As many as 84% of GPs agree that society’s approach to mental health has led to the normal ups and downs of life being seen as medical problems. Furthermore 85% of GPs are concerned that antidepressants are prescribed because non-pharmaceutical interventions are not available and 83% are concerned that antidepressants are prescribed when non-pharmaceutical interventions would be more suitable. In short, the vast majority of GPs are aware that they are inappropriately medicalising and treating things that they should not be but need the government’s help to change both their and their patients’ behaviour.”

Despite GPs attitudes that the above research reveals, they continue to prescribe antidepressants and other medications for mental health conditions. They are under enormous pressure to do so. Patients expect a solution. Culture determines that the solution is medication. GPs are not immune to this cultural pressure and they are after all predominantly trained in physical medicine.

Many politicians, support groups and commentators don’t recognise diagnostic inflation. They assume that if someone is diagnosed, they unambiguously HAVE a condition that is the cause of their difficulties. They don’t recognise the social/cultural processes behind the increase in diagnoses. They believe they are supporting vulnerable people who need help. But in effect that are encouraging more of us to think we are vulnerable and need to seek help. They don’t recognise the damage having a diagnosis can have on a person’s belief in themselves and their ability to understand and solve their own difficulties.  Of course, there will always be times when we need help and support, but diagnostic inflation has gone too far. There is no apparent limit to the social definition of conditions. If it continues on this trajectory there will be few of us without a character/behavioural pattern that is not classified as due to a mental health condition.

Losing benefits that you have come to depend on and have been led to believe you need can be a personal disaster. However,

Seeing physical and mental health as equivalent is a cultural disaster.

Ignoring the power of thinking is  a cultural disaster.

Diagnostic inflation is a cultural disaster.

GPs sit at a critical juncture in the welfare system. They face a dilemma. They don’t have the time to help patients see themselves as active agents whose thinking lies at the centre of their difficulties.

While the research by the Centre for Social Justice concluded that GPs “need the government’s help to change both their and their patients’ behaviour”, it is hard to see what the government can do. Politicians, for their part, need votes. They have their own dilemma.

In The Origin of Anxieties, I explore the intimate connection between our thinking and our experiences of feeling anxious.