From the Editor
Therapy can be life changing – especially for young adults who may be at the beginning of illness. The stakes are high but what are the outcomes?
In a new Lancet Psychiatry paper, Rob Saunders (of University College London) and his co-authors attempt to answer this question. They drew on an impressive dataset – from the National Health Service, with more than 1.6 million participants – and compared outcomes (both scales and service specific scores) between young and working age adults. “In a dataset of all individuals receiving psychological therapies for common mental disorders in a national service programme, we found that young adults had poorer outcomes than working age adults.” We discuss the paper and its implications.
With a few clicks of the mouse, our patients can read what we read – including the latest journals. But they also can access a world of half-truths, misleading claims, and falsehoods. In the second selection, a new episode of Quick Takes, I speak with Jonathan Stea, a University of Calgary psychologist and a bestselling author, about his research on the wellness industry. “The beating heart of the wellness industry is pseudoscience.”
And in the third selection from BJPsych Bulletin, Alan Levinovitz (of James Madison University) and Dr. Awais Aftab (of Case Western Reserve University) argue that there is benefit in a diagnosis. In a clever paper, they coin the term Rumpelstiltskin effect (yes, after the Grimm story) – that is, “the therapeutic effect of a clinical diagnosis, independent of any other intervention.” Are they persuasive?
DG
Selection 1: “Effectiveness of psychological interventions for young adults versus working age adults: a retrospective cohort study in a national psychological treatment programme in England”
Rob Saunders, Jae Won Suh, Joshua E. J. Buckman, et al.
The Lancet Psychiatry, September 2025
Depression and anxiety are the leading causes of disease burden in young adults, and they have become more common in this age group over recent years. Young or emerging adulthood is the phase of life beginning around 16–18 years old and considered to continue up until the end of the 24th year according to WHO. This important period of brain and social maturation coincides with a peak in the incidence of common mental disorders (CMDs). Timely and effective treatment of these conditions is crucial to long-term prognosis and to reduce the negative impacts of these conditions across the life course.
Psychological therapies are recommended as a first-line treatment for adults with CMDs, and in young adults they are particularly important given concerns about the risk-to-benefit ratio of antidepressant medication for this age group. Treatment recommendations contained in clinical guidelines are based on evidence from randomised controlled trials (RCTs), but the average age of participants in trials of treatments for CMDs (around age 44 years) does not reflect the mean age of adults treated in mental health services for such conditions (age 32 years). RCTs of treatments for children and adolescents span a broad age range, including childhood, adolescence, and young adulthood. Meta-analyses of response to cognitive behavioural therapy (CBT) from RCTs suggest that children and adolescents might have poorer outcomes than adults, but it is unclear to which specific age group this applies. Findings relating just to young adults compared to those in middle age are less clear, as while some studies have shown that younger age could be associated with worse outcomes, others have indicated no association between age and treatment outcomes, and others still have found that younger people could have better outcomes.
So begins a paper by Saunders et al.
Here’s what they did:
- They used data from all individuals who had treatment in any English National Health Service Talking Therapies for anxiety and depression service between April 1, 2015, and March 31, 2019.
- They compared change in Patient Health Questionnaire 9-item (PHQ-9) score and Generalized Anxiety Disorder Scale 7-item (GAD-7) score pre-treatment to post-treatment between patients who were aged 16-24 years and those aged 25-65 years.
- They also looked at service-specific outcomes including recovery, reliable recovery, reliable improvement, and reliable deterioration.
- “Age was also treated as a continuous variable in linear regression models examining change in depression and anxiety symptom severity scores.”
Here’s what they found:
- The young adult cohort had 309 758 patients aged 16-24 years; the working age adult group had 1 290 130 patients aged 25-65 years.
- Demographics. Young adults tended to be female (69.4%), White (82.5%), with a mean age of 20.8 years. The working age adults were also primarily female (65.2%) and White (83.6%), with a mean age of 41.5 years.
- Improvements. The changes for PHQ-9 and GAD-7 scores were smaller for young adults compared to working age adults (PHQ-9: b -0.98; GAD-7: b -0.77).
- Other changes. Young adults were less likely to meet criteria for reliable improvement (odds ratio 0.78), recovery (0.73), and reliable recovery (0.74), and more likely to meet criteria for reliable deterioration (1.19).
A few thoughts:
1. This is a good study, drawing on a robust data set (including GAD-7 and PHQ-9 scores), and published in a major journal.
2. The main finding in a sentence: “Psychological treatment outcomes were better for working age adults (aged 25-65 years) than young adults (aged 16-24 years), with a monotonic increase over age, even after adjusting for sociodemographic and treatment-related differences between the age groups.”
3. Ouch.
4. The difference is alarming. As the authors note: “scaled over the population attending psychological treatment services in England, amounted to worse outcomes for tens of thousands of young adults compared to those 25 years and older.”
5. The authors suggest several possible reasons, including that engaging this population is challenging. They make several recommendations, including: “Getting young adults into treatment more quickly, offering them treatment in a convenient and desired format, and working hard to ensure they stay in treatment have the potential to improve outcomes for this group.”
6. Like all studies, there are limitations. The authors note several, including the limitations of the measures which didn’t include things like wellbeing or a personal sense of improvement.
The full Lancet Psychiatry paper can be found here:
https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(25)00207-X/fulltext
Selection 2: “The Wellness Industry”
Jonathan N. Stea
Quick Takes, 1 October 2025
In this episode of Quick Takes, I speak with Stea. He discusses patient stories and the rise of social media. Our conversation covers everything from his mother to his research – and, of course, his new book.
Here, I highlight several comments:
On the wellness industry being worth an estimated $5.6 trillion
“This stuff keeps me up at night.
“I don’t like how our patients can be exploited by fake credentials, fake cures for fake diagnoses. It’s awful. And patients deserve better. They deserve the best care based on the best evidence. And the wellness industry doesn’t offer that.”
On social media
“I think things are a lot worse because the mic has been amplified, so to speak. And it’s been given to so many people who otherwise might not have it. The spread of misinformation and wellness grift just reaches more people.
“There’s been research that shows that, looking at the algorithms of Twitter, false information spreads further, deeper, and faster than truthful information within the network. I can recall one study that looked at popular ADHD related videos on TikTok. And when the authors analyzed the content of those videos, they found that about half of those videos were misleading. But perhaps the more kind of jarring aspect of that is that those videos were viewed millions of times. I was really fortunate to be recruited by a fantastic research team, and they asked me to participate in a similar study where we looked at the top 1 000 videos on TikTok with the hashtag #MentalHealth. And when we analyzed those videos for their content, we found that about a third were misleading. But those videos were viewed over a billion times.”
On ozone therapy (NSFW)
“Essentially, it’s putting ozone up various parts of our body, whether it’s the vagina or the backside. Obviously, it’s not an evidence-based treatment.”
On thought field therapy
“It involves tapping various parts of our body or our head to basically tap along certain energy fields or thought fields that are ‘unbalanced.’ And when we can balance these through tapping, then that’s going to somehow treat a mental health concern.”
On his personal connection
“I grew up as an only child in a house with my mom and dad. It was really loving home. But my mom, unfortunately, had health issues. She suffered an injury from a botched spinal surgery and that left her with a diagnosis of complex regional pain syndrome, which, back then, was called reflex sympathetic dystrophy – basically an umbrella term to characterize a whole slew of chronic pain-related symptoms. I saw those symptoms with my own eyes. Ultimately, mainstream medicine couldn’t help us. We tried everything. We also looked to alternative medicine treatments, literally everything under the sun. We tried psychics, incense, chiropractic, everything. And that stuff didn’t work either. And some of it actually made her feel worse.”
The above answers have been edited for length.
The podcast can be found here, and is just over 23 minutes long:
Selection 3: “The Rumpelstiltskin effect: therapeutic repercussions of clinical diagnosis”
Alan Levinovitz and Awais Aftab
BJPsych Bulletin, 22 August 2025
Consider the following clinical scenario: a 42-year-old history professor seeks a psychiatric evaluation for dealing with low mood, anxiety and poor self-esteem. Despite a successful academic career, she feels that she has not lived up to her potential and her efforts have been plagued by a persistent inability to focus, a tendency to procrastinate and difficulty completing tasks without last-minute pressure. These struggles have been present since childhood but were dismissed by her parents and teachers as laziness, to be remedied via rigorous self-discipline. Over the years she internalised these judgements, developing a harsh and critical attitude towards herself.
During the initial psychiatric assessment, her psychiatrist identifies characteristic signs of attention-deficit/hyperactivity disorder (ADHD), a diagnosis that is subsequently supported by neuropsychological testing. When informed of the results, she expresses a sense of tremendous relief at finally having an explanation. The official diagnostic term, despite its merely descriptive nature, seems to offer an explanatory lens that she had previously lacked. The new lens, in turn, had a profound therapeutic effect with improvements in mood, anxiety and sleep.
This clinical anecdote is a composite one for illustration, but it captures a real and widespread effect of diagnosis.
So begins a paper by Levinovitz and Aftab.
“Clinicians in a variety of disciplines and settings see this dynamic play out in diverse diagnoses: tension headache, tinnitus, chronic fatigue syndrome, restless leg syndrome, insomnia disorder, irritable bowel syndrome, functional dyspepsia, chronic idiopathic urticaria and autism spectrum, to name but a few. Their experiences highlight a striking, neglected and unchristened medical phenomenon: The therapeutic effect of a clinical diagnosis, independent of any other intervention, where clinical diagnosis refers to situating the person’s experiences into a clinical category by a clinician or the patient… We call this the Rumpelstiltskin effect.”
They draw on the children’s story. “In the classic Grimms’ folk tale, Rumpelstiltskin, a young woman promises her first-born child to a little man in exchange for the ability to spin straw into gold. When he comes to collect, she begs for mercy and he offers her a way out. She must guess his name… Now a queen, the woman runs through every name in the German language, as well as every colloquial nickname she can think of. None work. Finally, her servant discovers the little man’s highly esoteric name – Rumpelstiltskin – and she is released from her obligation.” The point: “Esoteric knowledge of an official name is required to gain control over what ails her. As soon as she knows the name, the problem takes care of itself.”
They note the connection. “Fundamentally, a clinical diagnosis invites patients to see their experiences through a medical lens. The medical interpretive framework recognises suffering in ways that everyday language often can not, because the latter tends to characterise problems as personal inadequacies. Clinical language is also more standardised than everyday language, which offers at least the appearance of a cohesive explanatory framework for a person’s impairment.”
They look to the literature:
- “A systematic scoping review by Sims et al developed a thematic framework for understanding the effects of diagnostic labels… The review found that diagnostic labels often provided individuals with feelings of relief, validation and empowerment. These labels helped remove uncertainty, facilitate communication and enhance self-understanding.”
- “O’Connor et al conducted a systematic review and thematic synthesis examining how psychiatric diagnoses affect young people. They found that the scientific authority inherent in the diagnostic label validated the authenticity of young people’s struggles and recast them as legitimate medical conditions…”
- “In a notable randomised controlled trial, Thomas studied patients with medically unexplained symptoms. The study revealed that patients showed greater improvement when their GP provided a firm diagnosis with a positive prognosis, compared with those who received neither. This improvement occurred regardless of whether patients received actual treatment.”
They give comment on a mechanism of action. “The act of diagnosis is, in most cases, a prelude to medical care and treatment. Another mechanism at play in the Rumpelstiltskin effect may be an acquired association between the naming of a condition in a medical context and the promise of relief and access to the ‘sick role’. When a patient receives a diagnosis, it offers hope and reassurance. The association can continue to play out even in situations where a diagnosis is made but treatment is not sought or none is available.”
They also note potential iatrogenic problems. “Particularly worrisome is when patients internalise the idea that their diagnosis identifies a chronic, intrinsic deficiency, which can foreclose on agency and turn diagnosis into a self-fulfilling prophecy. For instance, a diagnosis of an anxiety disorder could lead a person to engage in more avoidance behaviours, mistakenly believing that they will be overwhelmed, with the avoidance creating a vicious cycle of persisting anxiety.”
A few thoughts:
1. This is a clever paper.
2. Are you both excited and relieved like the queen?
3. Are some people gravitating towards diagnosis – and thus overdiagnosis? Is this the impact of TikTok where people find comfort in self-diagnosing themselves with autism, ADHD, and more?
4. Dr. Niall Boyce (of Wellcome) makes good comments on his Substack: “At the beginning of my career in mental health, I often heard the criticism that psychiatrists imposed their medicalised view of life on an unwilling public. But in recent years, the script has changed; now the concern seems to be that psychiatrists are doing an inadequate job of preventing people from labelling themselves. In this context, it makes sense to think of diagnosis as a therapeutic intervention that has escaped the professional bounds of psychiatry, and which, in the modern digital world, people can now self-prescribe.” Thoughtful.
The full BJPsych Bulletin paper can be found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.
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