Yesterday I was having lunch with a colleague. We both do sessions in the psychiatric emergency room. And we are seeing young men, acutely suicidal, following rejection by a partner. We both reflected on our young years. We were rejected. We were shunned… and my colleague said “But you had resilience”.

Both of us had more bullying and difficult experiences than the average person we have seen.

Then I read this article today. A couple of comments before the quote: the baseline suicide attempt rate and followup suicide attempt rates are high and increasing. The cohorts referred to were aged 19-23 in 1995, 2000 and 2005 and were thus born roughtly 1975, 1980 and 1085. The youngest is now in their thirties.

The paper is open source and well worth reading.

The increasing rates of DP with psychiatric diagnoses underscores that reliable and valid measures of functional impairment related to mental disorders are required, in order to secure equal assessments over time and between practitioners. Of note, the proportion with previous psychiatric inpatient care among the individuals with psychiatric DP diagnoses decreased from the 1995 to the 2005 cohort. In individuals of the same age without DP, this pattern was inverted, with a gradual increase in the proportion of individuals who received such care. Thus, it seems plausible that increasing knowledge about psychiatric diagnoses and the disability associated with such conditions has resulted in that young individuals with less severe symptoms (i.e., not requiring psychiatric inpatient care) are granted DP. However, it is equally plausible that the criteria for granting DP with psychiatric diagnoses gradually have become more lenient. Reliable standards for assessing functional impairment in patients with mental disorders have not yet been established. The ongoing efforts to categorize aspects of functioning that are likely to be affected in specific mental disorders, according to the International Classification of Functioning, Disability, and Health (ICF), could prove to be a major step forward in establishing such standards.

If we presume that the increase in DP with psychiatric diagnoses in part is attributable to an increased tendency to grant DP for less severe forms of the disorders, a decrease in severe outcomes such as suicidal behaviour among these young adults could be expected. A decrease in severe outcomes might also be expected, given the substantial change in clinical practice and availability of psychiatric care since 1990’s, with for instance a steady increase in prescription of antidepressants. Still, the risk of suicidal behaviour remained high over time among young adults on psychiatric DP. The relative risk of suicide attempt among young adults on DP due to psychiatric diagnoses decreased over time (compared with all other young adults of the same age not on DP). However, this was mainly explained by a steady increase in suicide attempts from 1995 to 2005 among the age group as a whole (the reference group) and not by a decrease among those on DP.

I don’t know a clinician who has not seen the severe end of attention dieficit or anxiety or autism/aspergers and noted their difficulties and disabilities. But there is a tendency to “give” these diagnoses at lower and lower thresholds — to the point that academics joke that every engineer and IT scientists is “a bit Aspie”. They are not.

The diagnosis may be crippling. Because being on a disability pension and not in an apprenticeship or in training or working or at some form of school at 19 is going to limit your income, your social circle, and your ability to move through the developmental issues of young adulthood, such as leaving the parental home and starting your own home and family.

It is a lot easier to sign a medical certificate than it is to sort out a learning programme, or engage a person in therapy, or tell them that work is good for their recovery (it generally is). I, like many working clinicians, worry that DSM is taken as a legal set of criteria that allow one into a system of care and shelter for mild and time limited distress instead of a researcher’s manual for sorting out treatments for the severely disabled.

It should be the latter.

Outside the narrow field of nosology and epidemiology, there is a wider issue: is the expansion of the social welfare state into the family and the increase of disability funding harming people? Would they be better on whatis now called locally a job-seeking benefit?

Perhaps a bit of hardship helps is grow. My colleague and I had our fair share of difficulties during our youth. Perhaps they allowed us to grow. Perhaps this young generation are left too long within a hothouse, and cannot thrive without.