E190 | New ADHD/Autism Review Set to Dramatically Change UK Mental Health Services

0:00 A major new government review has just been published about ADHD autism and mental health in general. Depending on which headline you read, you might think these conditions are massively overdiagnosed. The truth is actually a lot more complicated and uncomfortable than that. That's not really what the report says.

0:17 I treat and assess people with ADHD, so I decided to make a video about it. Today I'm going to explain some of the main points I think this review is trying to express, share some of my thoughts, and a few ongoing questions I have about some of the recommendations that it's making. So if you look at stories like this, they're often covered in quite a sensationalist way.

0:35 So for example, for this review, we have this headline from the Times saying ADHD label risks lifelong harm to children as diagnoses surge. And that's really, you know, very finely cherry-picking something quite sensationalist from this very complicated, you know, 600-page report. So really I think this review is asking two fundamental questions.

0:57 One, how should we understand the rise in mental health difficulties in our society in general and especially amongst young people? And two, how should services be changed in order to cope with this demand and to better serve people, essentially? The central argument that the report is making is not simply there is too much diagnosis, but rather that there's something about the current system that's that's not working.

1:22 People often have to wait for years for an assessment for something like autism or ADHD. And when they're waiting, they just don't have any kind of support or treatment. And as a result, this report is calling for a shift from what it says is our current kind of diagnosis-dependent system to what it calls a needs-led plus diagnosis system, and we'll talk about that a bit more later.

1:46 The report outlines some really core principles that it's using. So I had a read of the executive summary, which is about 26 pages. The full report is about 600 pages, so it's gonna take me a while to get through that. But it outlines some really interesting core principles. So one, it says population prevalence is not the same as administrative prevalence.

2:05 So what it means by that is there are there are different groups of numbers. There's the numbers of people that we think actually have a condition like autism or depression or ADHD, that's the population prevalence. And then there's the administrative prevalence, meaning how many people are actually getting diagnosed, how many people are on waiting lists.

2:24 The report says it makes a point of saying distress is not disorder. So it's saying if someone's in mental distress, having difficult mental experiences, that doesn't mean they have a diagnosable mental health condition. It's also making a distinction between diagnosis and need. So diagnosis is not the same as need.

2:42 A person may not have a diagnosis of a mental health condition, but they still may need support. Someone with a diagnosis of a mental health condition actually might be doing okay and may not necessarily have as much need. That's the distinction this report is trying to make. And it's also saying support is broader than treatment.

3:00 There are many different ways we can support someone as a society that could be in their education or in work or in personal life, and that doesn't necessarily mean like a medical treatment, particularly a medication-based treatment or perhaps psychological treatment. So I think that's important. What is this report saying about mental health in general?

3:21 So this report is saying actually mental health problems are on the rise, especially amongst young people. For example, it says the proportion of adults aged 16 to 64 meeting the criteria for a common mental health mental disorder, that would be like something like depression or anxiety, has increased by almost half from 15.5% in 1993 to 22.6% in 2024.

3:46 So Peter Fonegie, the psychoanalyst and psychologist who led this review, made a point of saying, you know, young people now they're not the snowflake generation. It's not that they're less resilient than other people, it's that life is generally quite hard, quite a bit harder perhaps than it used to be for lots of reasons, and therefore mental health conditions are on the rise.

4:07 The report also mentions self-harm and eating disorders are on the increase amongst young adults. And then interestingly, the report also mentions conditions like schizophrenia and bipolar, and that the prevalence of those conditions seems to be roughly stable. Then it specifically talks about ADHD and autism, and again, it talks about those two numbers: the population prevalence and the administrative prevalence, how many people are likely to have a condition versus the rate of diagnosis or people being on waiting lists.

4:39 And for both ADHD and autism, the review says that the population prevalence has roughly remained the same from the available data. There should be roughly the same amount of people in our population that has those conditions, but there is a vastly increased rate of diagnosis, an increased administrative prevalence.

4:59 And the the report is warning that we haven't actually reached a point of overdiagnosis yet. But if the rates of diagnosis continue as they are, it is likely we will get into overdiagnosis territory. So importantly, this review makes a point of saying currently ADHD and autism are not broadly being overdiagnosed, but that could we could get into that territory in the future.

5:22 I think that's an important distinction to make. What the report also talks about is the distinction between underdiagnosis, misdiagnosis, and overdiagnosis, and it takes them all quite seriously. So underdiagnosis is someone has a diagnosable condition, but they don't get the diagnosis. Misdiagnosis is they get a diagnosis of one condition, but it should have been a different condition.

5:45 And overdiagnosis is someone doesn't really meet the criteria for a particular diagnosis, but they get a diagnosis anyway. And the review goes out of its way to talk about all three problems and says all three problems could be an issue, and importantly, that all three could be occurring in the same system at the same time.

6:05 And I think this is important to mention because often when we talk about diagnosis, we do talk about it in this binary way, don't we? Like is a condition being overdiagnosed or not? But actually, you can have over-diagnosis, underdiagnosis, and misdiagnosis all occurring at the same time in a given system.

6:22 The report also talks about the difference between having traits of a condition versus a condition itself. So ADHD, for example, comprises many traits like distractability, difficulty staying on task, difficulty with time organization, difficulty with object organization. And the report says some people may have traits of a particular condition, like they may be distractable and have difficulty with time management.

6:49 That doesn't mean that they have ADHD because ADHD requires more traits, requires them to be present intensely, pervasively, causing impairment, stuff we've talked about before on this podcast. And then the review goes on to say, you know, gives a few possible reasons, sociocultural reasons as to why people are likely to be uh in more mental distress.

7:11 And it specifically outlines four one, more uncertainty and insecurity, including poverty, you know, financial insecurity, unemployment, housing difficulties, difficulties with education. Two, we live in a more evaluative and comparative society. So in education, in work, even in our social lives, everyone's comparing our everyone's comparing themselves to each other, and this is causing a lot of stress.

7:36 Three, it talks about less belonging and more loneliness, a reduction in youth and community provision and people feeling more on their own than they ever have before. And four, it talks about less opportunities for rest and recovery. More of daily life is spent online, there's less unstructured play, there's less um time in nature, everyone feels very busy, and there's always a million things on the table to be accomplished.

8:02 The review makes explicit that perhaps education has become a big contributor to distress, that education itself has become much more of a stressful experience, and it also identifies social media, something we've all thought about as potentially amplifying people's mental distress. The report makes a big deal of talking about independent providers and regulating them.

8:27 So you might know when it comes to things like ADHD and autism, there's a huge private market, both private organizations which treat uh assess and treat NHS patients, patients on NHS waiting lists, but also uh organizations who just see people in the private sector. And the report raises strong concerns about the quality and the consistency of those assessments done by private organizations.

8:52 And something I didn't know actually is that private clinics who just do assessments, who just do, for example, autism assessments or ADHD assessments, and they don't do any kind of treatment, they don't need to be regulated by the Care Quality Commission, which is a big deal because it means they're not subject to the same uh regulations as the NHS or private organizations which do do treatment, and the report calls for such organizations to also fall under that regulation.

9:19 And I think that's that's probably going to be important as well. So, as I said earlier, this report is advocating for this needs-led plus diagnosis kind of model. The review outlines that having this one gateway being diagnosed as the only way you can get help or support for your mental distress uh isn't working, uh, and many people may need support even though they don't reach a diagnostic threshold, and people who need a lot of support aren't getting diagnoses fast enough.

9:50 And so the the report describes that it wants to provide people with the right support at the right time rather than making diagnosis as the only route to help. So, those are some of the key facts I've been able to pull from reading the executive summary, which is about 26 pages. The full report is 600 pages.

10:06 I haven't quite gotten through that yet. Hopefully, I will soon. Here are some of my thoughts in the meantime. I think, firstly, this report tackles a lot of things. It's not just an ADHD and autism report, but it's a report that's trying to help us understand general mental health conditions in our society, why they're getting worse, and how to understand them.

10:26 I think the implication of this review is that ADHD and autism are sometimes being used as explanations for people's distress. And I think it goes out of its way to talk about the difference between traits, like having just a couple of traits of ADHD or autism, versus a fully fledged diagnosis. Because I think the subtle implication that the review is making is that when people are generally more mentally distressed, it might be more likely that they seek a diagnosis for something like autism and ADHD.

10:55 And so this review is saying we need to seek other understandings for why people uh get into mental distress, like other mental health conditions, like depression, uh lifestyle factors, sleep, other psychological factors, trauma, the other environmental factors like school or work problems, stuff like that.

11:15 I think the distinction between you know having a few traits and having a fully fledged condition, that's obviously, you know, it's true that sometimes someone can have traits versus uh having an actual condition. The problem is it's very hard to know where to draw the line, and that's really the whole issue of mental health diagnosis is where do you make that cutoff?

11:35 And it's also very hard to separate uh causation versus correlation. Like if someone's having difficulties at work, do they have difficulties at work because they have ADHD, or is there work-related stress causing ADHD-like symptoms? When you're seeing a patient, it can be very hard to tell those apart.

11:53 So I think that's going to be an issue in terms of how these recommendations are implemented practically. I think it's really good that the report is recognizing that you know, young people are the snowflake generation, that people are experiencing a lot of mental distress. And I think it's good that the review is talking about explanations which aren't just medical.

12:14 It's not just that people have a neurodevelopmental condition, it's also poverty, financial insecurity, uh, education feeling more stressful than it has, people being lonely and feeling a lack of belonging. I think it's good that it's attempting to outline more holistic explanations for why people get into mental distress because I think that's that'll be a useful path to solutions and recommendations as well.

12:37 I think it's important, of course, to underscore that as of yet we haven't reached this critical point of over-diagnosis. Perhaps we will reach it if rates of diagnosis continue as they are. Um, but it's entirely possible that rates of diagnosis may slow down as the administrative prevalence, the people are getting diagnosed, that number catches up with the population prevalence.

13:00 So obviously that's something we all know for some time, but I think it's important to keep in mind. And I really like that the review you know outlined it's not just about over-diagnosis, but you can have over-diagnosis, underdiagnosis, misdiagnosis. They're all problems we should take seriously, and they can all happen at the same time in one system.

13:20 Uh, the report makes a point of looking at the term neurodivergent and talking about how many people in school, maybe up to 20% of school children, can identify as neurodivergent. And I kind of I agree in that I'm not a huge fan of the word neurodivergent, mainly because it lacks a clear definition that we all agree on.

13:41 Neurodivergent isn't a condition, and usually people talk about neurodivergence when they're talking about ADHD, autism, uh, dyslexia, dyspraxia. Uh, and I think that actually leaves out a lot of people. Like, why isn't that people with schizophrenia, for example, or bipolar disorder might not fall under this umbrella, or people with vastly different uh genetics, or people with vastly different uh personalities?

14:07 I think neurodivergence is just not specific enough. You know, we are all different in lots of different ways, and people can sit at a lot of different extremes, you know, cognitively and and mentally. And so I think neurodivergence is a term that's gotten a bit too diluted, whereas, you know, ADHD has a specific clinical definition, autism has a specific clinical definition.

14:32 So it might be that a term like neurodivergence is kind of too vague to be useful. I really agree with the review saying we need to improve the quality of assessments in the NHS and the private sector, pretty much. We need to figure out a way to make our assessments better, and I agree that people just doing the assessment side absolutely need CQC regulation.

14:54 I think this is going to be a very uh big deal, and I think it's one of the major weaknesses is that there are assessments that can be carried out for ADHD and for autism, which are substandard. So I think that's a that's a good low-hanging fruit, I think, for improvement. My main uh question about the recommendations this review is making is again this move into the needs-led, you know, needs-led plus diagnosis model, and it's still not clear to me how that's gonna work exactly.

15:22 Again, there's a 600-page report we have to read. I think diagnosis is an inherent part of healthcare. By diagnosis, I don't just mean deciding what condition applies to someone, but just having a general sense of what someone's problems and needs are. So it's not super clear to me how you can provide great support without some kind of diagnostic process.

15:46 Maybe the review is suggesting there's a kind of generic support that can be provided to people, maybe support with education, uh, work, maybe some form of more generic psychological support while people are on a waiting list that could be useful. But as someone who's worked in a lot of different mental health services, it's not clear how they're gonna work that out pragmatically, what's that gonna look like on the ground and what are the weaknesses of that system going to be?

16:11 Like it's very easy to look at the current system and figure out its weaknesses, come up with a different system, but it's equally hard to anticipate what might be the weaknesses of your new system. And I think this system could potentially have a lot of weaknesses. I guess one question also that occurs to me is by what criteria do you judge who has the most need?

16:32 Is it people who aren't working? Is it people who have the least access to financial support? Is it people who self-harm? Is it people who report the most objective mental distress? And again, what about the people who might not show up on those criteria but who objectively have a lot of need, who would get missed in this kind of system?

16:53 It's kind of hard to decide who has the most need. So I think that might be an issue as well. And also, how do you decide who has the most need, again, without doing some kind of diagnostic process that's reasonably in-depth? I think this these are important questions. The uh review suggests perhaps the need for a comprehensive assessment.

17:13 Um, not just someone going for an ADHD assessment or an autism assessment, but an assessment that could capture their overall mental health and maybe diagnose something like ADHD or autism in addition, or not at all. How this comprehensive idea of a comprehensive assessment fits into this needs-based approach, again, I'm not sure where that's gonna fit in.

17:36 One thing the review talks about, which I really liked, was outcomes. So, what outcomes are we gonna shoot for? And is it just about people getting diagnoses or people getting prescribed medication? And the review says important outcomes should include things like participating in relationships, in education, in work, in family life, in community life.

17:57 And I really agree with that. I think that's a really good measure of, or those are potentially good measures of success because with outcomes like that, you're seeing how much of people are actually having a high quality of life, who aren't just you know ticking a box on a diagnostic form, but who are meaningfully able to like live lives with relationships, who can participate in society, who can learn stuff, who can contribute.

18:19 So I think that focus on maybe more holistic outcomes is is really really important, and I think that's that's a good thing. I still need to do a lot more reading about what this review says uh in terms of the issues and the recommendations, but what I like about it so far is that it's quite balanced and complex.

18:39 In a way, this is the kind of conversation I wanted to have when the channel 4 documentary about ADHD came out, which I yeah, I made a video on a couple of months ago. I thought that was a very binary, uh not very helpful way to have this conversation. But with this review, actually, I think we're getting into some really useful complexities and nuance and ADHD, autism, mental health in general.

19:04 By no means is this review dismissing any of that, but it's having, I think it's at least starting an intelligent conversation about what the issues are and perhaps how we could solve them. As I said, I'm still have some questions about some of the practical implications of this review, and this is just the the review itself.

19:22 The government still has to decide how it's going to implement these recommendations. So what's actually going to happen remains to be seen. In the meantime, we'll keep following this story and we'll keep you updated on the podcast. In the meantime, if you find this kind of content helpful, do like, subscribe wherever you listen.

19:39 If you're interested in sharing your thoughts on you know what you think this review is doing well, what it's done badly, do leave us a comment on YouTube. In the meantime, thanks so much for watching and we'll see you here next time.