Who Is Responsible For Over-Medicalisation? (Your Radical Questions with Dr Suzanne O’Sullivan)

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1:06Amol Rajan:And the spigot has like a 360 degree rotation, which is pretty cool. There's also this upgraded UV coating. They add it for free. So your hose basically looks brand new all the time. Right now, when you get the new Pocket Hose Ballistic, you'll get a free 360 degree rotating pocket pivot and a free thumb drive nozzle. Go to Pocket Hose dot com slash podcast. That's Pocket Hose dot com slash podcast. for your two free gifts with purchase. Pockethost.com slash P-O-D-C-A-S-T. Hello and welcome to Your Radical Questions. This is where I put your questions to one of our magnificent radical guests. And we have had a lot of questions this week.

1:46Amol Rajan:It's your chance to engage very directly with the very, very clever, very interesting and influential people that we have on this show and ask them about their ideas for the future. And Dr. Suzanne O'Sullivan has spent three decades in medicine, including 25 years as a neurologist. She's written lots of books, which lots of you, I happen to know, have absolutely adored, including the latest book, which is called The Age of Diagnosis. It's really sparked a national and, indeed, global debate about whether, to some extent, mental health conditions, but also perhaps physical conditions, are being labelled too readily.

2:19Amol Rajan:She argues that overdiagnosis is becoming widespread, and in the main episode, we talked about why she believes this is happening, what it means for how we understand mental health and physical health today, and why we should all think harder about the trade-offs when it comes to diagnosis. Now, she's here to answer some of your questions. Are you feeling ready, Suzanne? I'm ready. Ready, always ready. Here we go. Right, our first question is from Kate, who sent us this note on WhatsApp. Thanks, Kate. Is it appropriate for anxiety to be termed as a mental health illness rather than an emotion?

2:53Are we undermining those with other sometimes life changing or life limiting mental health issues by doing so? And are we limiting the life outcomes of anxiety sufferers by referring to their issues as mental health? I note that a huge number of NHS fit notes were issued for anxiety last year. And I'd be interested to know how many of our needs are in this category. Thank you.

3:21Amol Rajan:Kate, thank you so much. Is it appropriate? We'll start with lots of questions in there, which is a good compound question. Is it appropriate? We'll take them in turn. Is it appropriate for anxiety to be termed as a mental health illness rather than emotion, Suzanne? So I think the big challenge is that it's absolutely impossible to say where anxiety turns into a medical disorder because we're dealing with things that have no biomarkers. So we're always going to have a difficulty dividing up depression from low mood, anxiety that is a medical disorder from anxiety that isn't. And I think this is something really important that the medical community needs to work on.

4:00We need to figure out when is a medical label appropriate and when should something be conceptualised more as a difficulty that falls more in the social realm that could perhaps be improved with life changes rather than with medical treatment.

4:15Amol Rajan:Because the worry that Kate refers to in her third question is are we limiting the life outcomes of anxiety sufferers by referring to their issues as mental health? Look, just to translate this into kind of the fruitier language of politics, which actually you've steered very wisely clear off, both in your book and in the main episode, which people will have heard last Thursday. Some people say you need to toughen up. Toughen up. You need to get on with it, head down. You know, when I was young, we didn't have all this stuff around. You need to just deal with it. We shouldn't be medicalising the everyday ups and downs, which is how Tony Blair, in fact, spoke about it on a different podcast.

4:51Amol Rajan:Is a message of tough love, does a message of tough love have a kind of social value, do you think? Well, I think we've got a few different problems. First of all, if we call everything anxiety in an equal way, there are people who suffer with anxiety that is so disabling that they cannot function normally in the world. And we need to be able to divide those people out because those people need medical support of some sort. And I think the best way of dividing people out in that way is to try and establish, as best one can, accepting there will always be grey areas, how much is this anxiety disabling you?

5:24Is it stopping you doing normal things? Then we're probably dealing with something that needs medical attention. Or is it the kind of anxiety that you can potentially overcome? And then it might be better focused in the sphere of something that needs you to examine your life or for social change, etc. So I think that when we use these medical terms for anxiety in equal ways for very severe anxiety that is disordering and less severe anxiety, we're undermining that severe group. And we are potentially in using these medical labels, you know, if we call low mood depression and we give it that sort of medical kind of allure, we are potentially reinforcing that difficulty and making it seem less possible to overcome it.

6:10So I think when we over-medicalise, we harm everyone. We harm the people who definitely need medical help because we attract resources away from them and we undermine the validity of their suffering. But we also harm those with kind of lesser symptoms and lesser needs by potentially making their difficulties concrete through medical language.

6:29Amol Rajan:OK, thank you so much for the question. The next one is from Madeline. I'm just going to read it out. It's worth saying we had a few on this theme. And in fact, Madeline, so you know, in case you missed it, Suzanne addresses your question to some large degree, I think, in the main episode which came out last Thursday. Madeleine says, given the evidence that autistic people face extremely high rates of suicide, how can you justify reducing or questioning diagnoses? So I think the most important point here is that we are not talking about a diagnosis of autism or nothing. So I think people often kind of feel that if the diagnosis of autism has been taken away, that someone will not be able to get medical support.

7:08Teachers are able to support children without a medical diagnosis. GP can support a person without a specific diagnosis of a neurodevelopmental brain disorder. So we're not talking about neglecting people who are suffering. GPs, psychiatrists, psychologists, teachers, etc. are perfectly able to help people without those labels. I also think we need to apply a tiny bit of scrutiny to the science that tells us that there are very high suicide rates in people with autism. Very often when you look at those studies, what you'll find is they include people who have been diagnosed with autism according to very rigid criteria, along with people who are referred to as things as autistic traits, which isn't really a person with autism, or people who are self-diagnosed with autism.

7:58So you're kind of bunching a lot of people together, not all of whom have an official diagnosis. So I'm not doubting that people are suicidal. What I'm wondering is whether people who now have an emotional need, a practical need for support, are getting that support through the label of autism. So it's not that autistic people are necessarily very, have very high rates of suicide, but rather at the moment, a language of distress is autism.

8:27Amol Rajan:And just to say, we address this in the main episode, but you also accept that it may well have been the case that though on the one hand, because two things can be true at the same time, though on the one hand, the definition of autism has been expanded, it may also be the case that autism was including quite drastically underdiagnosed or underrecognised in the past. Listen, I've no doubt at all that underdiagnosis exists, and I'm sure it exists more so even in specific groups of people. People are less able to advocate for themselves, lower socioeconomic groups, people in socially deprived areas.

9:00There's no doubt that underdiagnosis exists, but that doesn't mean that we can also be overdiagnosing at the other end of the spectrum.

9:09Amol Rajan:Thank you very much indeed for that question, Madeline, and everyone who sent a question on that theme. we've got another one in which I'm going to read from someone who goes by the name of the little brown bird it's a lady who often responds to me on Instagram thank you very much she says how this i.e the book the argument of the age of diagnosis how the argument of the book affect women who are underdiagnosed and gas lit by doctors endo and adenomyosis etc again we're back in the territory of underdiagnosis and overdiagnosis can exist at the same time so I would deal so for example to talk about a condition that I deal with more as a neurologist, functional neurological disorders, which are psychosomatic conditions.

9:50Now, these are conditions that affect women more than men, and they have been massively neglected in medicine for decades. I would say really, research has only really been applied to these sorts of disorders since about the 2010s or so. And I would say that part of the neglect of that condition is because it is a female predominant condition. Similarly to endometriosis and other female predominant conditions, I think women haven't had a very strong voice. They haven't been properly listened to and that women have been neglected and that female predominant conditions have been neglected. However, the answer to that is not to apply this sort of over-diagnosis paradigm that tries to equate all different diagnoses so that men and women have exactly the same numbers of everything.

10:40What we need to do is make sure that we are listening to women, not just applying diagnosis for diagnosis sake.

10:47Amol Rajan:But to what extent, this is a question for me as opposed to one of our lovely listeners, to what extent is over-diagnosis the price of fixing under-diagnosis? Well, you're absolutely right. It is the price. And I think up until this point, we have considered a price worth paying. But I would say we haven't scrutinized that properly. And that price is turning into a cost. Well, if you look at, so what's the theory behind diagnosing more and more people with autism and ADHD and other special learning problems in school? The point is that you take children, you recognize the ones that are struggling, you give them a diagnosis, you give them support, and then somewhere downstream, that will pay dividends.

11:26Where is the dividends, I would ask? I would say that we have a growing population of teenagers with mental health diagnosis and neurodevelopmental disorder diagnosis, and we have an equally growing number of young adults with mental health diagnosis. So if this idea of preventing underdiagnosis by finding as many people as possible was working, we should at this point be seeing happier, better adjusted adults, and we're seeing the exact opposite.

11:54Amol Rajan:One of the things we didn't get into in the main episode, just because I felt that it's not that we were running out of time but just because I was not entirely sure about the context in which to raise it it's something that you will have given some thought to which is the extraordinary preponderance of ADHD and dyslexia it seems in our prison population it's a really interesting I mean I just you know I actually earlier this year sorry last year in 2025 I went with one of our brilliant producers on the Today programme to a young offender's home and I met four I can say this actually now I've checked, I can say this.

12:26Amol Rajan:I met four teenagers who had killed someone. And they all had ADHD. And the prevalence of ADHD in this institution was quite remarkable. I'm looking at a piece last year about understanding and supporting the needs of neurodivergent people in prisons and how it might be a human rights issue. And one particular piece says, authoritative estimates suggest half of the prison population may have some neurodivergent condition compared to 15 to 20 percent in the general population. A systematic review of international research suggests up to 27 % of people in prison have ADHD, and recent estimates in England and Wales suggest the prevalence of dyslexia in prisons could be over 50%.

13:06Amol Rajan:There are many challenges to the task of producing conclusive data on neurodivergence. These include the inadequacy of systems for identification and diagnosis, as well as the practical ways of reporting them in databases and internal systems. Do you know what, Susan? I don't even have a question about that. I just was very struck when I was, I'm interested in youth offending and crime. I don't know, how should we be thinking about it? I think, you know, so information, as you have presented it there, is often used as a sort of justification for making more ADHD diagnosis and interventions. I mean, first thing I'd say is, what is the biggest difference between those people in prison and me?

13:43I don't have ADHD. And I can tell you it's not ADHD. They probably grew up in socially deprived areas. They grew up in care. They grew up in very difficult circumstances. You know, sometimes when that information is presented to me, it almost feels like the whole reason that people are in prison is because they have ADHD. We'll actually...

14:01Amol Rajan:The issue is poverty. We're looking at it backwards. Yeah, we should be looking at, you know, what happens to socially people who grew up in care and people who grew up in socially deprived communities is that they have troubled lives. And we should be solving the poverty issue and not giving everyone ADHD diagnosis. I think the other thing that's really important to say about that is that argument is used constantly to make more diagnosis of ADHD. If you look at the statistics of ADHD, who are getting all, and I'm always talking, by the way, when I'm talking about overdiagnosis, the mild end of this spectrum, who's getting all these diagnosis?

14:38Well, I'll tell you who is. Private school students and mid-class people. So are we suggesting that all our ADHD diagnoses are stopping these people from going to prison? I mean, clearly, I think someone takes a statistic, dramatizes it and comes to a conclusion that I think is incorrect. I think what we know from these prison statistics is that we should be giving better lives to people who are in social deprived communities.

15:06Amol Rajan:And to be clear, even listening to the very precise way in which you choose your words, you're not saying that it's not interesting that there might be an over-representation, as it were, compared to the population level occurrence of dyslexia or ADHD. But I can say, and I can say this impartially with my BBC hat on, if you want to reduce the number of young people going to prison and you want to reduce the terrible crimes that some of them commit, sort poverty. That's exactly it. Make that your problem. And I say that I haven't spent 20 years trying to do just that. So even as I speak to you, Suzanne, there's such interest in the arguments of your book and your previous books.

15:37Amol Rajan:I've got questions coming in and I'm going to try and get through lots of them because that will give maximum value to our lovely listeners. In the meantime, before I play a voice note, which I've just had on Instagram, this is a question from Himashi. By the way, thank you to the little brown bird whose real name I don't know. But thank you to Himashi as well, who was sent in a question saying this is an email. is over-medicalization primarily driven by patient expectations, healthcare systems, or the medical profession itself? Let's just say it's a real folia de or whatever is more than de. Basically, it starts with, so the first thing that happens is that you coin a new condition.

16:16We talked a lot about autism, but it's a good example. You coin a new condition, and then scientific communities start studying it, and then when they start studying it, They find milder and milder forms and then the research spreads out and they find more atypical forms. So it often starts with science and with doctors trying to find solutions to things. And then what happens is we present our solutions and our diagnosis to people in need. There's always people suffering and looking for answers. So they will respond to that diagnosis by saying, I recognize something in that diagnosis. I think I have it.

16:54so we've got this kind of a desperate need on the behalf of one group for explanations for support for help for a language for distress and then we've got doctors and scientists desperate to meet that need so i think it's really uh sort of you know multiple factors play into it it starts with science it's driven by the need of the public and then all the opportunists the private practitioners the pharmaceutical companies come in and feed on that it's so interesting you say

17:23Amol Rajan:from James, a question for Suzanne from James on Instagram addresses that very issue and I just want to raise it here. He says there's been an explosion in adults asking their NHS GP and I should be very clear, Suzanne is an NHS GP herself, for assessment for ADHD and autism. The NHS criteria for diagnosis seem much stricter than private companies. If it isn't ruining your life, you are unlikely to meet the NHS diagnosis criteria. Still, functioning adults who get diagnosed privately report large benefits from treatment. If someone doesn't meet NHS criteria, but does meet less restrictive private criteria, are they neurodivergent or not?

18:01Amol Rajan:For these in-between patients, should the NHS be helping to fund life-improving treatment or not? What an interesting question. Thank you, James. Yeah, I mean, you know, it's almost impossible to find out what's happening in the world of kind of private practitioners, because certainly there seem to be more diagnosis coming out of private clinics than there are from NHS. If you look at some of the statistics, the NHS estimates it's making three to four percent of children are ADHD. But if you go into a school, then schools will often say they've got 10, 12, 13 percent of their kids of ADHD. So there's a whole bunch of diagnoses that aren't being accounted for that may well be coming out of the private sector.

18:44You are not supposed to get a diagnosis unless you meet strict criteria. But I would have to question whether every facility is meeting those strict criteria, because we have what we call conversion rates. How many people go into a clinic, get a diagnosis? And there are some clinics where 100 percent of people going get a diagnosis, which cannot be right. So I think not everybody is applying the diagnostic criteria correctly.

19:11Amol Rajan:OK, James, thank you very much indeed for that question. I don't know if you yourself work in health care, James. It would be interesting to know that. himashi thank you as well for your question about over medicalization final question comes from a huge fan of yours gwen um halbert who's a doctor in glasgow she's i should say when i put out on instagram that you were coming on this podcast huge response um you know unusually huge response and it was mostly from people who absolutely love your work and gwen sent me this voice note on instagram hello my name is gwen halbert i'm a doctor in glasgow um i am a massive fan of Suzanne O'Sullivan's work and it has really changed the way that I think about medicine and about how I do my work.

19:50Amol Rajan:I do have a question for her though. There was a huge backlash to her first book, particularly around the title It's All in Their Head and this became really quite a toxic discussion around the time and I think this reflects this difficulty that there is in us being able to speak to our patients about issues at any kind of depth. I wonder if she has any comments about how she handled that herself or if she has any hints or tips for how medical professionals can go on to have these complex conversations in a time when we often find that complex discussion is challenging or difficult and where we find ourselves facing complaints if we even suggest that investigations or further treatment might not be appropriate.

20:34Amol Rajan:So from one doctor to another what's your answer? Well you know first of all to say that I've I've had incredible support from doctors. So that's why, you know, I don't want more support than doctors and support than criticism. Oh, absolutely. And I absolutely I'm so mainstream. You know, I absolutely don't want to be the doctor who's out there saying things that everyone else, all the mainstream doctors are criticizing. So I've had phenomenal doctors have been so nice to me and I really appreciate that. And with regard to sort of toxic debate, honest to God, I'm asked that question a lot. And I will tell you every time I'm not I'm utterly unaware of toxic debate, you know, because I'll just be brutally honest.

21:14I mean, the age of diagnosis was extremely critically acclaimed popular science book of 2025. And it's all in your head was similarly critically acclaimed and won awards.

21:24Amol Rajan:I read the reviews. It's true that they were extraordinarily gushing across the board, actually. I really haven't had, you know, professional reviewers, journalists and doctor reviewers have all been very positive. And again, I'm really singing my own praises now. But if you go to Amazon, more than kind of 95 % of my reviews are four star and above. And yet people say to me, you've had a toxic backlash. Like, Gwen isn't the only person to say that to me. And I think what's happening is that people look on social media. Where you hear from the 10 % who are angry. By the way, I should say as well.