Balancing the media’s insatiable demand for hyperbole with painstaking scientific reseach is a tough gig – even for compulsively opinionated psychologists like Oliver James.

Look what happened to Raj Persaud
http://www.timesonline.co.uk/tol/news/uk/article4147576.ece

Raj Persaud’s claims were at least accurate.

Plagiarised in certain cases, but still accurate.

@ a&. Yup, but no one’s forcing them to be media whores, are they? They could have just worked diligently in mental health (though in James’ case, I’m not sure that would be an unalloyed good thing, given his, er, interesting conceits …)

Your argument would be stronger if you didn’t put words in his mouth. cf point number 1. He never said that a quarter were off school. And he never pretended his claim was based on anything other than a single study.

It isn’t clear what you mean by a 12-point questionnaire. If you mean a 12-item questionnaire, then what you should be assessing is the validity and reliability of the instrument, which may well be impressive and well-established. If you mean that responses were given on a 12-point scale, then that’s surely a good thing, because the questionnaire is sensitive to variation in the sample.

Was it Bob Marley who said “before you point the finger, make sure your hands are clean”?

@Clarice

The above article is something of a digest of things I’ve been pointing out on my blog about James’ questionable scholarship. More detail can be found about his claims regarding teenage girls can be found here.

But just to elaborate a bit further:

He never said that a quarter were off school.

True, but what he did say was, “27% are suffering a full-scale major mental illness (severe depression or anxiety)”. Now, the ICD-10 criteria for a Severe Depressive Episode states that, “it is very unlikely that the sufferer will be able to continue with social, work, or domestic activities, except to a very limited extent.”

If a child is attending school and coping with the school day, they almost certainly don’t have severe depression (mild or moderate, possibly, though they may need support to do so. But not severe depression).

And he never pretended his claim was based on anything other than a single study.

It isn’t clear what you mean by a 12-point questionnaire. If you mean a 12-item questionnaire, then what you should be assessing is the validity and reliability of the instrument, which may well be impressive and well-established. If you mean that responses were given on a 12-point scale, then that’s surely a good thing, because the questionnaire is sensitive to variation in the sample.

The questionnaire in the research paper he based his claim on is the General Health Questionnaire-12. You can find a sample of this questionnaire here.

It’s designed as a general gauge of somebody’s wellbeing, and does NOT provide a diagnosis. The research paper cited by James (online here) does not suggest that it does, and contains no claims that 27% of teenage girls have a severe mental illness.

Excellent article. Oliver James is a crackpot who has been given far too easy a ride in the liberal press because ‘Affluenza’ chimes in with the middle-class angst of newspaper columnists, and the generic anti-capitalist and anti-western cliches through which they think their opinions ought to be expressed.

My favourite of his claims was from Affluenza (or maybe it was the one after that). That it’s inequality that causes mental ill health. He then used the examples of the US, China, UK and Nigeria (from memory).

When you check up the Gini (a measure of inequality) you find that both Nigeria and China are more unequal than the UK and US. You also find that China and Nigeria have, in James’ own words, less mental ill health than the UK or US.

He was very pissed off when an editor accepted an article from me pointing out this bollix of his.

@Shatterface

I quite agree. Maybe I’m being cynical, but part of me thinks his scholarship would be questioned a lot more than it is if it didn’t chime so nicely with bourgeois concerns and anxieties.

I’m very familiar with the GHQ. Perhaps if you’d explained in your article that the instrument used was not a diagnostic tool, your argument would have been stronger. Making a diagnosis from a non-diagnostic instrument would be high on *my* list of objections, if *I*”d looked into things as you have. Being a “12-point questionnaire” does not make something invalid, which seemed to be the argument you were relying upon.

Also, if people need to read your other stuff to be able to make sense of or evaluate what you have written here, why not do away with this article and just give us a link to the stuff that *does* make sense?

Clarice, I’ve been given 800 words to write a digest of three articles here, so unfortunately that requires me to be brief and concise.

However, all those articles are linked to in the above digest, along with James’ articles and the papers that he (mis)quotes. Feel free to explore them.

Presumably you were aked to write this so as to get the point across to people who haven’t read your blog. If you bear that in mind, you’ll realise that what you have or haven’t written elsewhere is initially going to be of no interest to the uninitiated reader. Like it or not, whether or not I am going to be motivated to read more of your material is going to be largely dependent on whether the points are well-made in this particular article, and slagging someone off for using a perfectly well-validated 12-point questionnaire while missing out the fact that they were using a non-diagnostic tool to make diagnostic inference just doesn’t kind of seem that great to me.

Presumably also, the purpose of a digest is to kindly summarise the arguments for people who don’t have the time to study the original posts in depth. Being “free to explore” the further sources you cite is not the same as being required to do so in order to evaluate what you have written here. If you can’t make the argument soundly in a stand-alone post, without arrogantly demanding your readers also wade through reams of other material, then perhaps this isn’t the medium for you.

Clarice, far from “missing out the fact that they were using a non-diagnostic tool to make diagnostic inference”, I feel I made that point perfectly clear, with the following words:

It’s based on a single research paper that surveyed teenage girls in Scotland with a 12 point questionnaire about their general state of happiness. It concluded that teenage girls were generally less happy than they used to be, but offered no diagnoses or claims about epidemiology of mental illness.

As for your other criticisms, kindly allow me to reply in the form of a song.

I liked Britain On The Couch: I think he’s lost his way since then and it’s interesting to look at his Wikipedia entry and note that after having three books published over a seven-year period, he’s had three more published over the past nine months. That’s not a good sign – where people start churning it out they’re often rather less scrupulous in checking their facts or coming to conclusions than they ought to be.

[2] Plagiarised in certain cases, but still accurate – yes, assuming the source material was of a higher standard than that presented by the likes of the media addicted psychologist?

My point though was that even reputable clinicians will still bend the rules, or even cheat (or in James’s case tell the odd porky) presumably so as to satisfy the media’s insatiable demand for ‘psychology-lite’ – especially any story which involves an alarming threat to middle class, yet curiously dissatisfied female teenagers?

Zara, why are you so angry at this guy? Yes he gets it wrong sometimes but he is brilliant at bringing the link between in utero experience, neurophysiology, attachment, genetics, environment and family life to outcomes for the general public in a way that they can understand. What is so wrong with that? Not everyone has the time or inclination to read Sue Gerhardt’s “Why Love Matters”

What is so unbelieveable in the number of 27% of teenage females being depressed, anorexic, body dysmorphic, substance addicted etc – it doesn’t seem so far fetched to me having been a female teenager myself. In all the mental health books I have been reading it is highlighted that its very difficult to pick up mental health issues where it is internalised as is often the case in girls- and I have many friends who were star athletes and students as teens who later went onto have breakdowns as their depression wasn’t picked up earlier as they were so good at pretending everything was ok.

Why do we only have to wake up to someones mental distress when they are at crisis and either attempt suicide or break down completely and have to be sectioned. That’s very much the national mental health system as it is now – that you have to be screaming naked down a road brandishing a samurai sword before someone helps you.

You really surprise me and your anger at this author is completely misplaced.

have to be sectioned

Not a phrase I’m particularly fond of, that. A lot of people are sectioned and people always say they “had” to be, it’s the default phrase. But it ain’t always so.

Hi Lilliput

I’m not angry at Oliver James, well, not all that angry. I’m simply pointing out that on repeated occasions he’s talking demonstrable rubbish.

You say that:

he is brilliant at bringing the link between in utero experience, neurophysiology, attachment, genetics, environment and family life to outcomes for the general public in a way that they can understand.

but what good is that if the links he describes are simply not accurate?

What is so unbelieveable in the number of 27% of teenage females being depressed, anorexic, body dysmorphic, substance addicted etc

Well, then, if it’s the case that 27% of teenage girls have a severe mental illness, then I’d like to see some epidemiological research justifying that claim. The research James cites does not claim anything of the sort, regardless of what he’s saying about it.

From the Saneline website:

“One in four of us will be affected by mental illness at some point in our lives.”

I may be wrong but 1 in 4 means 25% no? So is he 2% wrong? What am I missing here?

What you’re missing is the word “severe” in severe mental illness. The 1 in 4 statistic has been disputed at times, but it’s generally understood to encompass the spectrum of mental distress, including mild episodes of depression or anxiety.

Oliver James’ claim is:

27% are suffering a full-scale major mental illness (severe depression or anxiety)

One in four of us may experience some sort of mental ill-health at some point between cradle and grave, even if it’s a mild, transient depressive episode. That is not the same thing as saying 27% of middle-class teenage girls have a severe mental illness.

No, zarathustra, you did not make it clear. The phrasing you used could equally well apply to something like the BDI (I wouldn’t use that description to refer to such a thing, but I’m sure that plenty of people would). As for the other points I raised, I rest my case.

I feel the same as Liliput – it isn’t clear from the article that your anger is justified, and if you really want to see some studies on the incidence of anxiety and depression in teenage girls, there are plenty of studies that *do* address this question that you could have used to inform your view, *and* your critique of Oliver James.

Also, having looked at the West and Sweeting article, I can’t help but notice that the GHQ ‘caseness’ figures are a specifically a reflection of psychological distress and not “general wellbeing” as you put it, and moreover it would appear that the GHQ has very good predictive validity. So on reflection, it isn’t actually clear that your objection to the GHQ, or to the conclusions drawn in respect of the mental distress/illness of the sample is very sound.

And if you read the results section, you’ll see the analysis wasn’t just done on the GHQ scores anyway. The confirmatory factor analysis found a very respectable fit for the three-factor model based on anxiety/depression, loss of confidence/self-esteeem and anhedonia/social dysfunction, and the subsequent anova results based on these factors appear to be what’s driving Oliver James’s interpretation.

I see nothing amiss with this research whatsoever. Oliver James has no case to answer in respect of your critique number one. I think you owe him an apology.

and ps Did you even read the introduction? It is positively littered with references to research on the incidence of behavioural and emotional disorders and psychiatric symptoms in the age-range in question…

[20] Well, we may be moving into the realm of semantics Clarice but I see OJ’s pronouncements (on middle class girls) as being on par with other ubiquitous psychiatric diagnose such as the burgeoning rate of post traumatic stress disorder (especially following a relatively innocuous life event)

Here’s one paper that considers PTSD in relation to various dodgy employment claims.
http://www.connellfoley.com/documents/MTL_PTSD.pdf

Anybody who has worked in one of the old asylums (as I have have) will find it impossible to view the worried well (OJ’s constituency) in the same light as those with severe, enduring and extremely disabling mental afflictions typified by the so called ‘negative’ symptoms of schizophrenia, for example.

At least that’s what I understand by the term severe mental illness and I think that is the point Zarathustra is taking issue with?

But a&e that’s exactly what I am talking about. Of course we cannot compare someone’s dysthymia with another’s schizophrenia but if the former begins drinking or shooting up – they will lead themselves and the people around them to experience much the same issues.

He is trying to highlight the gravity of mental ill health of the nation – of course he will use hyperbole by puting the word “severe” in front of mental health – especially when it is such a subjective thing anyway.

Well, a&e, I think you raise a very interesting and important point.

Most people who suffer from a mental illness are not suffering from psychotic symptoms, and most don’t require hospitalisation either. So no, those symptoms do not typify the mentally ill. The perpetuation of the misconception among laypeople that mentally ill = psychotic or schizophrenic is very damaging to the rest of the clinical mental health population. As is the insinuation that anything other than schizophrenia is not severely debilitating for the sufferer.

Zarathustra is muddling things up. No-one but him is claiming that 27% of teenage girls have a severe mental illness. What Oliver James actually said is that 27% have severe anxiety or depression. You see how that changes the sense of what is being claimed. And looking at the analyses, OJ’s claim looks about right. Either zarathustra got confused, or he’s taking a cheap shot at the man and hoping that no-one will see it for what it is.

My previous comments had nothing to do with semantics, unless you count objecting to people saying things that aren’t true or accurate, and/or grossly misinterpreting a statistical analysis.

The devil is in the detail, but if one is going to criticise other people’s details as zarathustra is doing, then perhaps it helps to get one’s own details correct beforehand.

Zarathustra is muddling things up. No-one but him is claiming that 27% of teenage girls have a severe mental illness. What Oliver James actually said is that 27% have severe anxiety or depression.

Argue among yourselves about whether or not severe anxiety or depression constitutes a severe mental illness, but the bottom line is that severe anxiety or depression would imply that they were so debilitated by it that they were unable to continue with everyday schooling. That’s how the definition of severe depression or anxiety works.

If they’re able to continue schooling in spite of it, then it almost certainly doesn’t fall within the ICD-10 definition of severe depression or anxiety. As far as I can gather, we do not have a quarter of our teenage girls off sick from school with a mental health problem.

Either way, the research paper that James cites does not suggest that 27% of teenage girls have severe depression or anxiety.

Actually, the research paper does suggest exactly that. The 27% you can see very clearly in the graph on page 582, which is using the more stringent cut-off. The link between GHQ ‘caseness’ and mental illness is strongly established elsewhere through validation studies of the GHQ. GHQ caseness is found in well-replicated prior studies to be predictive of mental illness diagnoses. The factor analysis and the anova on the factor scores, and the results on the individual items then go on to clarify the predominant nature of such mental illness as is suggested by the 27%, namely depression and anxiety.

It looks as though the “severe” angle comes from the number and extent of symptoms reported via GHQ.

You may also want to note, as you are so keen on ICD-10, that the diagnostic categories for mood disorders of childhood and adolescence do not admit of gradations of severity, so where you are getting your “ICD-10 definition of severe depression” from, to be objecting to the severity claim, I do not know. You surely can’t be applying the diagnostic criteria for adults to this sample, because that would be very clearly inappropriate.

Clarice, not a single child and adolescent psychiatrist that I work with would ever diagnose depression on the basis of the GHQ-12. It’s 12 questions, with highly subjective answers (“more than usual”, “less than usual”). It doesn’t give the patient a physical examination to rule out any physical illnesses that could mimic depression. It doesn’t actually observe the behaviour of the patient in the real world, away from a tick-box set of questions. It doesn’t take a physical or mental health health history, or a family history, and so on.

As with any tool, it’s necessary to read the instructions.

The General Health Questionnaire is a screening device for identifying minor psychiatric disorder.

Note the use of the word “minor” above. It does not identify the “major mental illness” described by Oliver James.

We should also note that we’re talking about the shortest version of the GHQ in this particular study, the one that’s been whittled down to 12 questions. The manufacturers don’t claim you can diagnose anything from it. They suggest that it be used, “in research studies where it is impractical to administer a longer form”.

In asserting that, “GHQ caseness is found in well-replicated prior studies to be predictive of mental illness diagnoses”, you might wish to note that there are different versions of the GHQ and, as I’ve said, this paper uses the shortest of the lot. Other versions have 28, 30 or 60 questions. The most validated one is the 30 question version. Even the version that goes up to 60 questions is only recommended by the manufacturers to “identify potential cases for more intensive examination”.

In summary, you don’t diagnose people on the basis of tick-box questionnaires.

Is it inappropriate to use gradations of mild/moderate/severe depression in adolescents? My experience of child and adolescent psychiatrists is that some do and some don’t, though they’re more likely to with those who are getting into late adolescence and closer to adulthood.

Whether or not it’s inappropriate, the bottom line is that Oliver James did make the distinction of “severe” depression or anxiety, and therefore I felt it necessary to call him out on what severe depression actually means. It ain’t a case of being a bit down in the dumps.

No-one is saying that anyone diagnoses people on the basis of the GHQ. What they’re saying is that, in view of the well-established and highly respectable predictive validity of the various versions of the GHQ (including the 12-item one), GHQ caseness is an indicator of mental illness. If you want to ignore all the research that says this is so, upon which the paper in question is premised, then that’s up to you.

You’ve also missed my point regarding childhood/adolescent depression. You were objecting to Oliver James’s claim regarding severity, and your grounds for so doing was the adult criteria for depression on ICD-10. I was merely pointing out that your application of adult criteria to adolescents was inappropriate. Which you don’t seem to have countered.

I think you are over-interpreting what Oliver James said. When he referred to severe depression, that was (by definition) in the context of the research he was quoting – ie depression as indicated by GHQ. No-one is saying that severity of symptoms on GHQ correlates with severe depression as per adult ICD-10 criteria. Read the research for what it is, and leave the poor man alone.

Teenage girls are unhappy… I must say I’m shocked.

For all the pedantics going on here over turns of phrase ect, the obvious point is this: He contends that 27% of the girls tested were in the midst of a full-blown mental crisis- “Severe depression or Anxiety” By referring to it as a “Major Mental Illness” he medicalises it, and thus it should meet the accepted medical test. In mental illness that is the ICD-10 or the DSM-IV criterion. The point Zarathustra seems to be trying to make is that it is incredibly hard to believe that this is the case.

Why does it matter?
A) When we medicalise the normal, if unpleasant parts of living ie being a teenager and being hormonal and living in a world that frankly stinks sometimes, we do these girls an injustice. A chance to grow, and (if needed, with help) face challenges and learn to regulate emotions a natural part of growing up. Do they need support? Definately! Does it need to be from Mental Health? Maybe…if parents are unable to offer it, schools are overstretched. Do they need to be labelled and taught that their feelings of unhappiness are something that is ‘wrong with them’…hell, no!

B) So, we have an influx of parents bringing in their girls in response to the emotive hysteria engendered by this article. Something is wrong with my daughter… she is unhappy… treat it! 27%…heck, yeah there’s a pretty good chance then that my daughter is severely mentally ill… So those resources are all tied up, medicalising and ‘treating’ these normal teenagers, and the parents who have the seriously disturbed young girl, who can’t get out of bed, can’t stop crying, self-harms, and has for all intents and purposes withdrawn from the world entirely, are left in a queue, waiting for their daughter to be attended to by an overworked and under resourced Mental Health industry.

It DOES matter, when people who are supposed to be experts in their field, manipulate and sensationalise data, for the sake of selling newspapers. It DOES matter when so called experts blur the line between unhappy and mentally ill. It has consequences for the individual, and for the system that is trying to support mentally ill individuals.

Ophelia, do you ever think that the mental health services are overworked because they are always dealing with clients that have reached crisis situations. Why does someone have to get to not getting out of bed or crying non stop before they can get some help? Why can’t a teenager who feels unhappy most of the time get some help as well? We are talking about preventative measures here and I’d be overjoyed if parents were taking their unhappy teenage daughters to get some help. Of course life is not allways rosy but feeling like shit most of the time is NOT normal – and that is a message we have to get out there.

Well-said Lilliput.

I think it’s dangerous, wrong, and a betrayal of those teenage girls, to attempt to “normalise” the many and severe symptoms of depression and anxiety they are suffering. Quite aside from the ethical argument, there’s the economic one. What predictive validity means is that GHQ caseness predicts diagnoses of mental illnesses. Which is why it matters that people with their own axes to grind don’t succeed at rubbishing or minimising this perfectly legitimate finding. It’s not sensationalism and it’s not manipulating the data. The Oliver James article is a very fair reflection of the research, whether certain people understand the methodology or not.

“It DOES matter when so called experts blur the line between unhappy and mentally ill. It has consequences for the individual, and for the system that is trying to support mentally ill individuals.”

Nicely put, Ophelia. Couldn’t have written it better myself!

@Clarise

Zarathustra said a 12 point questionnaire about their general state of happiness

Clarise said Perhaps if you’d explained in your article that the instrument used was not a diagnostic tool, your argument would have been stronger.

The Oliver James article is a very fair reflection of the research

This is as patently untrue as the original article. It was written for people just like you, who think, and perhaps rightly so, that endlessly repeating an un-truth will eventually cause it do a backflip and rightly take its place on the Throne as The Man.

Seriously, if 27% of teenage girls were seriously mentally ill, Oliver would’ve been beaten off the blocks into print by, well, everyone.

Can we have a declaration of Conflict of Interest before you continue to debate?

As Ophelia says, I think we possibly need to step slightly away from the semantics/pedantics about the validity of the GHQ-12 (other than to state, as a child and adolescent mental health nurse, that my faith in it is nowhere near as unshakeable as Clarice’s).

As others have pointed out in this thread, there is a need to distinguish between unhappy but normal feelings on one hand, and outright mental illness on the other. People will always debate where one draws the line, but my own view is that it is a line that needs to be drawn.

Any statement that “27% of teenage girls are mentally ill” clearly oversteps that line, and sticks medical labels on common-or-garden unhappiness.

@Lilliput

Why does someone have to get to not getting out of bed or crying non stop before they can get some help? Why can’t a teenager who feels unhappy most of the time get some help as well? We are talking about preventative measures here and I’d be overjoyed if parents were taking their unhappy teenage daughters to get some help.

Perhaps if I could answer this coming from my own perspective of Child and Adolescent Mental Health Services (CAMHS).

Much of the work of Child and Family Clinics – the first port of call in CAMHS for families who’ve been referred by the GP – involves working with people and assessing whether their problem is a psychosocial one – school, family problems etc, or an outright mental health problem. Much of what we come into contact with turns out to be the former rather than the latter.

If it’s purely a psychosocial problem, we can help by offering brief CBT and counselling, but we’re not the only people who can help, and in some cases they may be also helped by, say, pastoral support in school, or social services, or voluntary agencies such as Barnardos. Often we can signpost people onto these services.

In addition, we make increasing use of Primary Mental Health Workers – an experienced nurse or social worker who’s job is to liaise with schools, GPs, voluntary bodies – any organisation that works with children but isn’t a mental health service. They provide liaison between them and us, enabling advice and support to be offered if they have a kid who they’re concerned about, as well as brief assessment to see if that kid might be supported by, say, a school counsellor, or whether there’s evidence of underlying mental health issues that might need the attention of CAMHS. This can help get kids not just support but the right type of support. It can help ensure we see the kids we need to see, and also that those kids we don’t need to see are getting help elsewhere.

I’d say that’s a more intelligent way of approaching the issue than scare stories in the Guardian claiming 27% of our kids are mentally ill.

Zarathustra,

The problem I have with this set up is that fact that the psychosocial and mental health issues are very interlinked ie if a child is being neglected – then yes he needs a social worker as its a psychosocial problem but he also needs therapy with a person qualified in dealing with attachment disorders as he is most likely not securely attached. A social worker, pastoral carer, teacher etc are not trained to do it. In fact most teachers, GPs, and social workers have very little if any training in mental health issues and treatments.

Its not rocket science to think that if kids have psychosocial problems that they will have corresponding mental health issues. Although you take the child physically away from a bad situation – they still need help in healing the scars.

The problem is not over medicalising – the problem is under resourcing of qualified personnel. This is especially pernicious since the troubled children of today will make up at the prison and addict population of the future.

Have to say I don’t quite understand what’s wrong with writing a journalistic piece based on one piece of research evidence (the BBC, for example, do it all the time). Journalism is not the same as scientific reasearch and you wouldn’t expect to find (or want to read) a piece of academic meta-analysis in your Sunday paper.

The second point that there is no agreed definition of “hapiness”, no objective way to measure it (certainly not at the individual level) and therefore no empirical basis for investigating it. It is certainly not the same as depression.

Actually I’m very angry with this article, it just adds to the ‘feminization of madness’ band-wagon which started in the 19th century. From feeble-mindedness (a category in the old MH Act) to neurosis and the ‘poorlys’ (apparently all women now suffer some symptoms of PMS.) Women in long-term violent relationships are being diagnosed as suffering from learned-helplessness and so it goes on.
In fact female suicides over all ages have sharply decreased since the 1970s, but the suicide rate of young males between 15-24 is increasing, furthermore, drug and alcohol abuse has substantially increased within that age range. But this is mostly young males from the lower social classes so I don’t suppose it counts as they are not the usual Guardian readership
I, too, was once a female teenager and suffered the usual melancholy, angst and sadness but if we carry on medicalizing these normal feelings we will end up with half the population diagnosed with a mental illness.

jb – let me ask you this:

A friend of mine is a paediatrician, she often has 14yr old girls coming into the ER with an OD. On asessment the girl says she took an OD cause her boyfriend dumped her or she had a fight etc – does she get refferred for any further mental health treatment – probably not as I guess there is a “rational reason” for her to do herself in, however, realistically – what state of mental health must one be in to want to die after being dumped or having an argument – how can you say that she is at that moment – mentally healthy?

Lilliput,
At the moment of writing I have several of lifes’ problems going on around me, I have a very ill close relative who is terminal, my son has just lost his business and my partner is just recovering from quite a major operation. I do not feel very rational I feel upset and yes, I want to cry, I am at work and we are short-staffed. I built-up my coping strategies in my teenage years, and it wasn’t from being taken to a+e or to the mental health services because I was dumped by my boyfriend. Perhaps too many 14 year old girls are reading articles by pop psychologists whose definitions of mental illness,is, at best, ridiculous. Perhaps teenage girls do not understand that when someone says “I want to die” because their boyfriend has dumped them, it is a metaphorical statement, but then it maybe that some psychologists don’t understand.

@Matt Munro

Have to say I don’t quite understand what’s wrong with writing a journalistic piece based on one piece of research evidence (the BBC, for example, do it all the time). Journalism is not the same as scientific reasearch and you wouldn’t expect to find (or want to read) a piece of academic meta-analysis in your Sunday paper.

Maybe, but Oliver James is not a journalist. He’s a clinical psychologist.

I’ve read enough of Ben Goldacre’s work to understand that you can expect journalists to cherrypick, misinterpret or distort the research evidence. You don’t expect a supposed authority in the field to do it.

While Oliver James has recently made some bizarre claims, this article is pointing out an important research finding. He did emphasise that all classes of girls now have similar levels of self disclosed distress, and that we need to understand why. Why so many girls and to a lesser extent boys now admit to emotional distress is of great importance to the health and well-being of society. The alternative explanations might require quite different responses from society.

James should have reported the potential alternative explanation (which the researchers acknowledged) that the girls may find it more socially acceptable to discuss emotional and social problems now than previously. In other words that the GHQ is no longer performing well in teen girls in urban UK. While not diagnostic for the individual, the GHQ (one of the most used instruments worldwide) is recognised as being good at predicting rates of depression and severe depression. James was technically correct to suggest that according to the GHQ’s previously demonstrated predictive properties, rates of severe depression have increased. (PLEASE don’t confuse severe mental illness (eg schizophrenia ) with severe depression. James didn’t.) He should have alluded to the possibility that the GHQ is, due to changes in culture, performing differently.

We do need to investigate why GHQ scores are rising so dramatically. The girls’ talk is likely to provide the answers. Some good qualitative research can look both at their views about how distressed they really are and the causes. Both the pressures of affluence and poverty are likely to play a part. Analysing the talk – perhaps using Conversation Analysis – will help us explore the meaning behind the use of emotional language. Are they more in touch with their emotions and responding appropriately to the traumas of adolescence, or is this ‘emotional intelligence’ gone a step too far, with habitual negative utterances actually generating distress? Or are they really just more ‘depressed’ than girls used to be? Further quantitative studies incorporating the findings would then be needed to reach definitive conclusions.

The girls (and boys) will also be able to help us develop the best forms of help for this distress (even if rates are half those quoted). Ophelia is right that mental health care (drugs or psychotherapy) is unlikely to be the answer. And that a diagnosis in most cases is not in its self helpful and could be harmful. This bring us to the so called line between unhappiness and mental illness, which Ophelia suggests we should not be blurring.

While I agree that we should not be medicalising the appropriate distress of girls (or boys), even when it results in a one off overdose (with high GHQ levels at that point in time), which can be a salient learning experience. There remains a serious question of how much to medicalise those who do meet criteria for moderate and severe depression. The criteria, developed over years by ‘experts’ are a construct which we have created. The line could have been drawn at a different point. Currently the hurdle is quite low, so you only need to be very distressed for 2 weeks to fulfill the criteria for severe depression. If we raised the hurdle less young people would be deemed to have depression. Some people with quite high resilience, but succumbing to moderate distress brought on by high levels of trauma or abandonment, would then go unnoticed. They probably could do with some form of help and support.

So perhaps we do need to blur the boundaries a bit and not take the ‘expert defined’ line as gospel. Assess each case as an individual. Blurring the boundary between family medicine/general practice and specialist mental health services can also be helpful – low level but decisive psycho-social interventions can be integrated into a non-stigmatising setting. Wherever possible we need to empower our young people to utilise their own resources to deal with the problems of both affluence and inequality.

jb, firstly I hope that things work out for you as it does sound lik eyou have a lot to handle there. Secondly there is a huge leap from saying, I want to die and taking an OD and having your stomach pumped in the ER.

Richard, i love your idea of blurring the boundries – it came to me this evening as I was talking to a friend over dinner – talk about collective unconscious!

I think it is reasonable that people without mental health diagnoses can benefit from mental health services eg therapy, i certainly can’t seem to see the harm.

[41] We do need to investigate why GHQ scores are rising so dramatically.

If we really accept that more than a quarter of young females are ‘mentally ill’ then this must support the ‘sick society’ hypothesis as opposed to some sort of new biological phenomena?

As a father of x2 teenagers daughters I am willing to accept that adolescence is in itself a kind of crises – at least for my bank balance which is presently propping up a serious ‘addiction’ to nights out, rock festivals and facebook – where’s Zarathustra when you need him, eh?

@Lilliput

I think it is reasonable that people without mental health diagnoses can benefit from mental health services eg therapy, i certainly can’t seem to see the harm.

I do have some sympathy with this view, and for the record in CAMHS we don’t necessarily wait for a formal diagnosis before offering services such as therapy. We do engage in a certain amount of the “preventative mental health” support that you’re advocating.

But the brutal truth is that we only have a certain amount of resources, and that means they do have to be targeted at those for whom the need is greatest. Cast the net too widely, and you could pick up a few people who are in the very early stages of a psychiatric disorder, but this would be swamped by a larger number of “false positives” – people with transient, non-psychiatric problems that would eventually be resolved whether they get a service from us or not.

Is it a resources issue? To a degree, yes it is. But if we’re talking about a large amount of resources for a small gain, then it’s always going to be a hard sell to policymakers.

Where does one draw the line between who needs a mental health service and who doesn’t? For the record, I’d say it isn’t at the level where people are OD’ing and whatnot. I’d agree with you that people should receive support before it reaches that level. If we’re talking about childhood depression, then I’d say the point at which there’s a need for CAMHS involvement is the point at which some of the more physiological signs of depression – reduced energy levels, disrupted sleep patterns, impaired concentration and short-term memory – start to appear. If there aren’t any of these signs, then school support might be more appropriate, with liaison in place from the Primary Mental Health Worker just in case teachers or school-based counsellors start to develop new concerns about the child.

@43 – I think your kids have spun you a yarn if you’re giving them money for facebook…

This issue of resources is interesting. But what if we did have resources to invest in mental health care for children and young people?

Children with mental health problems – both anxiety and conduct disorders – are more likely to go on to have psychiatric and criminal justice careers, or just never find employment. This is where taking both and an individual and public health perspective is critical. Primary prevention (often involving working with parents or teachers to prevent problems) and secondary prevention (or early intervention) for problems in childhood and adolescence to prevent later more serious or chronic problems, can be effective (although we need more evidence to determine best strategies). The potential for later savings (reduced prison costs, benefits savings and mental health care) is enormous, but due to uncertain and delayed effects this kind of prevention is rarely invested in.

If resources were forthcoming – we would be left with the risk of labeling large numbers of children in order to offer interventions. This is why we probably do need to blur the boundaries, with mental health of children becoming everybody’s business. Low level interventions for many (often directed at family and wider systems to avoid scape-goating and stigma), and more intensive interventions for those in real trouble. Young offenders for example have high rates of mental illness – but usually the last thing they need is the stigma of a diagnosis, far better to integrate mental health care into programs supporting them achieve their personal goals.

Some may argue that people gain comfort from being ‘given’ a diagnosis. Yes, indeed while most people do appreciate knowing they are not alone and understanding the origins of the symptoms they have – my experience is that it is still possible to explain symptoms with reference to past experiences and basic brain science and without recourse to definitive labeling. Diagnosis can then be used for defining the need for additional specific interventions, and need not be central to the experience of getting support and help.

So I remain hopeful (perhaps deluded!) that we can achieve prevention and better support for distressed young people while avoiding the problems of disempowerment, exclusion and labeling.

@Richard Byng

So I remain hopeful (perhaps deluded!) that we can achieve prevention and better support for distressed young people while avoiding the problems of disempowerment, exclusion and labeling.

I agree actually – with the proviso that the support in question doesn’t have to include just the support provided by CAMHS – in-school counsellors, Sure Start, Scouts and Guides, voluntary organisations like Barnardos – they too can do a lot for the self-esteem, self-confidence and life skills of vulnerable kids.

Don’t get me wrong – I’m not suggesting that CAMHS hand over its responsibilities to Barnardos or school counsellors. But what I am suggesting is that good liaison and inter-agency working between CAMHS and these organisations can achieve more than simply CAMHS acting alone.

As you say, the mental health and psychosocial wellbeing of children should be everybody’s business, and not just something CAMHS do. This can and should be done without medicalising troubled kids (don’t get me started on any rants about “oppositional defiant disorder”, because I won’t stop…)

Zarathustra, I know how you feel about ODD but I look at it from the point of view that it helps people understand that there is something wrong with the child as apposed to them being “born evil” – which is something I can have a good rant about!