If you look at broader indicators, such as dropping out of school, youth unemployment and delinquency, you see a fall more than a rise in many countries. That does not fit the story of a generation that is collapsing mentally on a massive scale. After the coronavirus pandemic there was a clear peak in anxiety and depression, but we do not yet know whether that is a lasting trend or an adequate reaction to a disruptive period.
The problem with the DSM lens
The temptation is great to stick a DSM label straight away on every young person who comes in. But the DSM describes; it explains nothing. It does not say WHY this young person is getting stuck now, why these complaints arise in this particular context, or what is needed to get things moving again. More than that: there is research showing that children with ADHD-like symptoms who received an official diagnosis at a young age had more emotional and social problems and a poorer self-image at the age of thirteen than children with comparable symptoms without a label. That is a very good reason to be careful with early diagnosis.
Stuck in a tunnel
Mental distress can be better understood as a tilt in how someone relates to their own feelings, thoughts and desires. A feeling or thought is then no longer something you observe, but something that rules you. The panic that means you no longer dare to go to school. The emptiness that says there is no future any more. The girl who can only speak about herself in terms of trauma, burn-out or ADHD. Behind those words there is often not only the pressure of symptoms, but an experience of being stuck. In a tunnel.
Context first, label later
If mental distress is contextual, then you also have to look contextually, with young people too. That means: first understanding what is happening in the young person’s life. What is going on at home, at school, online, in friendships, in sleep, in identity, in their picture of the future. Where something to hold on to has been lost. Which environments unsettle and which help.
Sensitivities and talents
That view also fits a neurodiversity approach. Instead of thinking only about which disorder someone has, you can also ask: what profile of sensitivities and talents do I have in front of me? Where does this young person clash with the environment, what takes a disproportionate amount of energy, what goes well? That way of looking is slower to turn everything into a medical matter, without minimising the distress. There is work to be done, but it is worth the effort.
Young people as the canary in the coal mine
There is another reason why a purely individual reading falls short. Young people are sensitive to what is happening in the world. Climate threat, war, housing shortage, pressure to perform, constant comparison through social media, the loss of a self-evident belief in progress. Part of mental distress is a signal from society. Not everything that appears in the consulting room belongs in a disorder category. It is easier to diagnose an individual than to question a society. But much mental distress has a relational, social and lifestyle context. Pressure to perform, exclusion, loneliness and loss of connectedness are quite often reduced to the individual and seen as mental health problems, while they are partly socially produced.
What then? Four steps
- Ask about the distress itself. Not only counting symptoms, but asking what the young person experiences, when the dysregulation occurs, what happens in the body and in relationships. That is informative, and it brings relief in itself.
- Make the context explicit. Which environments unsettle, who are the supportive figures, how are sleep, rhythm, pressure at school, loneliness.
- Look at the profile. Sensitivities and talents. Where can the environment be adapted before a whole care circuit is set in motion.
- Steer the request for help towards life. Not every young person primarily needs specialist mental health care. Sometimes there is more to be gained from a trusted adult of their own choosing as a supportive figure, support for parents, coordination with school, sport, group activities, recovery colleges, peer-run recovery centres, informal support. There is almost always a whole range of resources outside a formal referral to mental health care.
Not only the consulting room, society too
Plus the big step. Because if mental distress is partly socially produced, you cannot solve it in a consulting room alone. Then you also have to do something about the circumstances in which young people grow up. That sounds vague, but it does not have to be. In Iceland they did exactly this. The government, together with schools and municipalities, invested on a large scale in sport, clubs and associations, parental involvement and organised leisure time for young people. No therapy, no diagnoses: simply making sure that young people belong somewhere, do things and have adults around them who are involved. The result was spectacular: substance use and mental health complaints fell sharply.
Compare it with how cardiologists work. They have developed wonderful techniques: heart operations, transplants, stents. But they say themselves: the real gain is not in the operating theatre. The real gain is in the simple message that everyone knows: do not smoke, eat healthily, exercise. Thanks to that public health message, heart disease in the Netherlands has fallen from the first to the second cause of death. Psychiatry and psychology have not yet taken that step. What they say implicitly is: only we can help you with the stirrings of your soul. While we have long known that exercise, good sleep, social connection and rhythm have an enormous effect on mental wellbeing. That message, what you can do YOURSELF, should be the main message. Not a footnote in a brochure.
The DSM in its place
The DSM does not have to go in the bin. But it is time to put it in its place. Young people who suffer with their mental health are not by definition psychiatrically ill. Often they show that their relationship with feelings, thoughts, relationships and the future has become dysregulated. Less reflexive labelling, more understanding of what has got stuck here, for this young person, in this world.
Jim van Os
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Prof. dr. Jim van Os, Chair Division Neuroscience, Utrecht University Medical Centre. Jim works at the interface of ‘hard’ brain science, health services research, art and subjective experiences of people with ‘lived experience’ in mental healthcare.
Jim has been appearing on the Thomson-Reuter Web of Science list of ‘most influential scientific minds of our time’ since 2014. In 2014 he published his book ‘Beyond DSM-5‘, and in 2016 the book ‘Good Mental Health Care’. In 2026 he published 'Wat psychisch lijden is'.
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