in Thinking about psychiatry

‘One in four’

One in four of us have a mental health disorder. Ruby says it (and Stephen Fry too), so then it must be true. But has one in four people I pass in the street really got a diagnosable mental health problem? If this sounds like rather a lot, then it is: 15 243 750 people from the last estimate of the UK population.

I emailed the Time to Change Campaign to ask them where they got their numbers from and, seemingly unable to provide any hard evidence themselves, they pointed me toward the webpages of Mind, the Royal College of Psychiatrists and the Institute of Psychiatry. Pause for a minute to consider that a campaign that is happily promulgating ‘one in four’ via television advertisements and on London-wide posters is unable to produce simple evidence for it to an interested party on request. Of the three websites, that of Mind is the most helpful and points towards two surveys, the references of which are below. Both of them use population surveys to come their conclusions.

But before I get to that, think about this; in his book Blink: the power of thinking without thinking the eloquent Malcolm Gladwell essentially posits the following thesis: if you are faced with something and your first reaction is ‘that’s bollocks’ (my phraseology) then this inner voice should not be ignored; it well might be correct. I put it to you that ‘one in four’ statistic is just such instinctual bollocks and it is only because it is told to us by ‘experts’ and written all over our world that it is accepted as fact.

Because anyone like me who’s in the business of identifying mental health disorders knows one thing. Sometimes it’s very difficult to do and untangling symptoms of reasonable distress from those of functional mental illness is more often than not utterly impossible. I’ve written before about people whose ‘career’ as psychiatric patients involves being given a number of different classifications on which any two psychiatrists often disagree. What hope then for surveys whose aim is to tease out these same symptoms with scant regard to the whole person whose reasons meanings and circumstance will be complex and opaque? Thus ‘one in four’ is a vast overestimate reached in part as life is hard and distress but not ‘mental illness’ is widespread.

Sadly the more something is repeated, the more it is accepted as fact. And this is true doubly if it is coming from the mouth of a celebrity. But soberingly: even if these numbers are not real, they may be real in their consequences and in a world where 25% of the population is mentally ill, we get what we deserve. In the UK 2.5 million working age people are claiming disability benefits, and only 20% of people claiming these benefits will return to work within the next five years. This amounts to massive waste of potential and one which doctors are expected to police, despite often not even having received ten seconds tuition on the matter whilst at medical school or since.

Yes there is a significant number of people in the population with serious problems in their mental health, and yes, Time for Change’s aim to reduce mental health stigma is laudable. But their ‘one in four’ slogan is an untruth sold to them by foolish psychiatrists. Time for change indeed…


From the MInd site:

ONS 2000, Psychiatric morbidity among adults living in private households in Great Britain,
States that the number of people with a mental health disorder in the UK at any one time is 1 in 6 people. This number represents those with ‘significant’ mental health problems.

Goldberg, D. & Huxley Common mental disorders a bio-social model which uses a wider definition of mental illness and correspondingly provides us with a ‘one in four’


Derek Summerfield has written about similar especially with regard to the Layard proposals


Addendum 27 May 2009 The excellent Neuroskeptic has begun looking into this.  In his first posting he looks into the basis of the ‘one in four’ claim, and was unable to find the basis of the claim

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  1. Well, their phrasing is intentionally ambiguous. A “mental health problem” doesn’t necessarily mean a diagnosable mental illness so if they had a disclaimer that would be it. As you say, diagnosing mental illness is a complete minefield. My brother has an autistic spectrum disorder and he also gets very depressed and for several years psychologists, psychiatrists and his GP have given conflicting opinions on whether or not he is clinically depressed. I always thought he was, having suffered from severe clinical depression myself, but I’m not a doctor. My instincts turned out to be correct. He is now on Sertraline and his mood has noticeably improved since he’s been on it. It’s funny how when you’re mentally ill and you have been in treatment so you have some insight into your own illness, you see it more clearly than a mental health professional who’s never been mentally ill ever could.

  2. I assume it is just a way to get people to think about mental health in a different, less negative way. I also assume that they are classing episodes of depression and possibly stress/anxiety as mental illness to boost the numbers. Maybe it is not the most responsible campaign, but anything that helps to remove the stigma attached to many mental health problems is probably a good thing. And maybe good for your business too!

  3. A very well written piece.

    While I agree completely that mental illness in it’s most insidious or debilitating forms is both under reported and poorly treated, I feel that the claim of 25% is both unhelpful and trivialising.

    I think that the disagreement on diagnosis (or classification) amongst psychiatrists for a number of patients represents an unhelpful reliance on a shared ‘vocabulary’, based on ICD10, DSM4 etc, but that face-to face, most psychiatrists, discussing a case in detail, would have a fairly shared understanding of the worries/distress/risks/needs of the person that they see.

    Do we all experience worries/distress/risks/needs? I would hope so. We are, after all, human, poetic, comic and tragic. Though not at a level that constitutes illness.

    Is there a significant proportion of people who have a significant mental illness? Undoubtedly.

    We must, both as a society, and as a smaller group, psychiatrists, consider what we feel to be the amelioration of suffering and the treatment of illness.

    Both will begin with kindness. Political matters will, I hope, follow.

  4. I thought it was 1 in 4 people have mental health problems *at some time in their life*. Sorry, don’t have a reference to back that up and have too much to do to spend time googling it right now.

  5. The one-in-four does actually come from the 2000 Psychiatric Morbidity Survey. It is the number of people ill over a 1-1.5 year period. (The one-in-six you cite is for a single point in time only).

    The survey finds 16.5% have a neurotic disorder at one point in time, and a further 6% develop one over the following 1.5 years. A further 4.4% have a personality disorder, and 0.5% a psychotic disorder (both are annual prevalences). Total = 27.4%.

    The diagnostic tool used to measure ‘neurotic disorders’ (the CSI-R) counts anyone scoring 12+ as having ‘significant symptoms’; as a rule of thumb, it is said anyone scoring 18+ is likely to require specialist treatment. Around half of the neurotic disorder group score 18+. So the estimate of the total needing specialist treatment would be around 16.15% (half of the neurotic group plus all of the personality and psychotic groups).

    Perhaps this is why you, as a psychiatrist, think the one-in-four sounds too high – because many of these people are not so severely ill they need specialist treatment.

    Whether this means they are ill at all is obviously what you are disputing, and yes, the topic of how to diagnose people is very much a live debate in the field. But it seems rather harsh to describe the PMS results as “an untruth sold to them by foolish psychiatrists” – it’s from the UK’s only nationally representative survey, run by the Office of National Statistics, with the advice of many experts, using well-established diagnostic tools.

  6. I’m not hugely surprised by the numbers, and I’m not hugely surprised that specialists such as FP are sceptical.

    The numbers reflect people meeting criteria for mental health disorders (MHD), but not necessarily those people seeking help. Bebbington et al (2003) found something like a third of people who met MHD criteria had not approached their GP for help in the preceding year.

    Of those who do seek help, it seems only about 50% are accurately ‘diagnosed’, or classified as meeting MHD by the GP (Goldberg & Huxley 1992), although this may have changed as training has improved.

    Of those who are classified appropriately, many will be given antidepressants and perhaps also referred to primary care mental health. We know many get stuck on a waiting list and often do not attend their assessment. If referred to psychology there are parts of the country where 2-year waiting lists are the norm. I may be wrong but I doubt CMHT’s (and psychiatrists on those teams) will encounter very many people who meet criteria for so-called neurotic conditions, unless they’re suicidal to the point of hospital admission, in crisis or present a risk to others.

    In the context of healthy scepticism regarding the concept of mental illness and disorder, I think the 1-in-4 figure is a useful one in terms of normalising and destigmatising the experiences people have. It can also encourage people to question the concept further, and to question the reductionist biological paradigm peddled to them indirectly by drug companies.

  7. Hello Frontierpsychiatrist, thanks for another thoughtful article. I started reading some of your Blogs recently as I have become obsessed with trawling the internet for mental health information!

    Having spent the majority of my life being happy, supported and much loved, this security disintegrated in recent years because my Father had a breakdown and killed my Mother. He is now sectioned and we are all slowly picking up the pieces.

    The one in four statistic seems like it is quite possibly accurate to me now under the circumstances. And I think that for most people, their mental health will at some point suffer, leading to a diagnosis of a mental illness. I have been amazed at how many friends and acquaintances have subsequently disclosed to me that they have been unwell, seeking support from specialists, taking antidepressants and even admission to hospitals – all of which I was completely unaware of.

    Not to mention that 1 in 7 pregnant and postnatal women are also affected by mental illness. Male suicide is also another area of mental health that is greatly overlooked. I am personally aware of three men who have taken their own lives in extremely violent ways. All of whom seemed to be unable to find a way to ask for help.

    If this campaign can raise awareness of the suffering that so many people go through often desperately alone, then I think that it can only have a positive outcome.

    I would love to back all of my comments up with research, facts and figures, but I can’t be arsed!!! I am on my way out to the gym!

    As for me, talking, increasing my awareness, helping others to understand, counseling, good friends and still finding a way to laugh in the face of adversity – are coping mechanisms that I use to now fumble my way through daily life without my Mum here with me…

  8. Thank you, these are some of the best comments that my blog has ever had.

    I still think that ‘one in four’ or even ‘one in six’ fails basic reality testing. If we think that 16.5% of people have a neurotic disorder at a point in time we should think carefully about our models. It will come as no surprise to some readers that I think that mental health services should restrict themselves to serious mental health disorders and mild/moderate anxiety and depression should be normalized as part of all our lives.


    Incidentally I had a thought today which informs this debate to an extent and also the on-and-off discussion Paul and I have had about psychiatric classification. I think that the ICD-10/DSM IV are useful whereas Paul prefers a treatment on the basis of distress model (Paul I hope I’m not misrepresenting this).

    Paul is a psychologist and myself a psychiatrist. As a psychiatrist it’s often my job to decide whether people are qualify as being mentally ill or not. This could be anyone, and all comers and I often see people in A&E. Therefore for me to make a decision of who to treat or admit on the basis of distress would be difficult.

    Psychologists on the other hand often have patients referred to them, and have less of a role of weeding out mental illness. Rather than offering patients some help ‘on the spot’ they work with them over a number of sessions. In this instance I can see that a distress based model would work better.

  9. A bit late to the party but I’ve just started a fairly length examination of 1 in 4 here

    The number appears in a whole range of places and it goes back about 5 years, but the source of it remains mysterious.

    So I was absolutely fascinated to read that you’d emailed the Time to Change people about it and they hadn’t known either!

    The interesting thing is that all of the studies which have tried to estimate lifetime prevalence have returned much higher values, 1 in 3 to 2 in 3 (sic) with 50% being common in US studies. There have been no such studies in the UK to my knowledge.

    The WHO in 2001 quoted a lifetime figure of “at least” 25%, which was widely quoted in the media as 1 in 4, but I checked the refs and the studies they cite in fact give estimates of 30-65%.

    My suspicion is that 1 in 4 is the number which is high enough to be striking, while not so high as to be outright laughable. if you take the data seriously it should be more like 1 in 2…