Mental health's access movement succeeded because it was built on a simple, compelling story. That story is now under strain. Unless the field develops a more coherent narrative about the causes of distress, the boundaries of healthcare and the path towards better outcomes, it risks losing the political and financial consensus necessary for progress.

Hi friend,

In the last two decades, we’ve seen remarkable progress in mental health.

Particularly, in getting people access to care.

What was once a taboo subject is now openly discussed in homes, workplaces, boardrooms and government offices around the world. Stigma has fallen, insurance coverage has expanded, and millions of people who would once have gone without treatment can now access it.

The access movement had a compelling narrative: that the primary barrier to better mental health was access to effective care.

Over the course of the last twenty years, we have seen huge increases in spending and the availability of care. In the US alone, expenditure on mental health and substance-use treatment rose from $41B in 2001 to $140B in 2021, significantly outpacing overall healthcare spend.  

With this increased spending, we saw an increase in the number of people who received care. In 2022, 23% of US adults received mental health treatment, an increase of four percentage points from 2019, which equates to a change of 21% in just three years.

Yet the success of this access movement leaves a hard question to be answered: why do we continue to see such high rates of mental disorders?

In 2023, 29% of US adults said that they had had depression over the course of their lifetime, up from 20% in 2015. Many more statistics on the prevalence of mental conditions look similar to this chart.

The stakeholders who supported the access movement are beginning to reconsider their role in mental health.

Financially, employers, insurers, and governments face rapidly rising mental health costs. Tim Noel, CEO of UnitedHealthcare, recently noted that behavioural health costs are increasing between 20% annually. Employers have expanded mental health benefits, yet many continue to see rising absence, disability claims and lost productivity. Increasingly, they are asking not whether people should receive care, but which forms of care demonstrably improve outcomes and justify continued investment.

Politically, governments and research funders are becoming more cautious. In the US, we have seen significant cuts to research spending and many mental health programmes. Year to date (as of July 2026), the number of grants the National Institute of Mental Health has funded is down 88%, versus the same period in 2024. The Make America Healthy Again movement has brought attention to psychiatric prescribing and concerns about over-medicalisation, particularly among younger people. The political conversation is shifting from expanding access to defining the appropriate role and boundaries of mental healthcare.

Culturally, new narratives are emerging. Some argue that we have over-pathologised normal human distress. Others go much further, questioning the legitimacy of mental illness itself. Many of these arguments don’t withstand scrutiny. But they are gaining momentum and reflect a wider societal unease about what is happening to mental health and whether the existing story still explains it.

Simply continuing to increase access to care will not keep these stakeholders on board.

The field will need to answer some hard questions and create a new narrative that addresses the reality of 2026’s challenges.

Narratives are how complex systems organise themselves. They shape what governments fund, what employers buy, what investors back, what researchers study and what ideas founders pursue. The access movement succeeded because it aligned these groups behind a common understanding of the problem and a broadly shared theory of change. Without a similarly coherent organising story, the mental health ecosystem risks pulling in multiple directions and losing support of key stakeholders along the way.

This doesn’t suggest that support for mental health is disappearing. Across the field, hundreds of thousands of clinicians, researchers, advocates, founders and policymakers continue to dedicate their careers to improving mental health. Millions more support the cause because of their own experiences. The motivation to improve population mental health remains strong.

The question is whether that motivation can be organised around a sufficiently clear account of the problem and the path to progress.

To create a new narrative, the field must explain why psychological distress remains so widespread despite two decades of increased spending and access to care. It must offer a more compelling account of what is driving this distress, and provide a clearer vision of where the next generation of solutions will come from.

There are many potential answers to these questions.

Decades ago, biological explanations dominated public understanding of mental illness, epitomised by the idea that depression resulted from a "chemical imbalance". That account has largely given way to the biopsychosocial model, which recognises that mental health emerges from the interaction of biology, psychology and social circumstances. It is almost certainly a better scientific model. But it is a much weaker public narrative. If genes, relationships, work, housing, technology and economic conditions all shape mental health, what, exactly, is driving rising distress? And where should society look first for solutions?

Simple explanations, by contrast, gain traction and drive change. Jonathan Haidt’s Anxious Generation movement is a clear example. Haidt offers a straightforward account of cause (social media use) and effect (the decline in adolescent mental health), which has become one of the most influential narratives in global health. Australia has already banned social-media use for under-16s, and the UK is pursuing similar measures. The actual efficacy of these policies is still hotly contested among academics, and yet huge action has been taken.

This challenge is compounded by uncertainty over what exactly is changing. Distinguishing between worsening illness, greater awareness, and changing definitions of impairment is becoming a central challenge for mental health policy. 

For example, in recent years, the number of young people reporting mental-health conditions has risen sharply, alongside increases in reported anxiety, ADHD, autism diagnoses and disability. Yet the picture becomes less clear when looking at functioning. Analysis of British data by Christoph Henking and Ben Baumberg Geiger found that while the share of young people reporting a mental-health condition increased substantially, the share saying that a mental-health problem limited their day-to-day has changed much less. 

At the most severe end of the spectrum, however, in several countries, hospitalisations for self-harm among teenage girls and young women have risen sharply.

This data supports a narrative of a teen mental health crisis and could be used to support policies like social media bans.

And yet, other analyses have shown that in many Western nations, teen suicide has actually decreased as social media use has risen. This includes the UK, where from 1995 to 2023, the suicide rate for people under twenty fell by 22%.

If this picture feels confusing, it is because it is. The problem is not simply that mental health is difficult to measure. It is that different measures tell different stories. And when we see multiple stories, it’s hard to align on where progress should come from.

What remedy are we proposing?

Over the years, I’ve spoken to researchers, clinicians, policymakers, founders and public health experts about what we need to do to create a mentally healthier world. There is little consensus.

Some look to better pharmacology, others to AI or neurotech, while many argue that, unless we change the social and economic environments in which people live, rising distress will continue regardless of healthcare innovation.

The theory of change implicit in this approach has therefore become more difficult to communicate. It suggests that mental health is influenced by many interacting factors, measured imperfectly and addressed through an increasingly diverse set of interventions. All of that may be true, but it is the kind of complex and nuanced narrative that struggles to organise cultural and economic forces.

Finding a new narrative

While defining specific metrics is challenging, most people would actually find it easy to agree on the world they want to see. It’s one where we limit unnecessary suffering, enable people to function in their families, workplaces and communities, and create the conditions in which people can flourish. Achieving that vision will be difficult. It will require a clearer understanding of the problems we are trying to solve, the outcomes we are seeking to achieve and, critically, where the next generation of solutions will come from. Most importantly, this understanding must be packaged in a compelling narrative that provides direction.

One possible route is to stop presenting mental health as a single problem. Severe mental illness and more common conditions, such as anxiety and depression, share important features, but they are not the same challenge. SMI requires better treatments and support for a smaller group with profound needs. The latter involves a much larger population where the boundaries between healthcare, normal distress and social conditions are less clear. Presenting these as distinct narratives to stakeholders could be beneficial.

Whatever route it takes, the field now needs a new organising narrative: one that is clear, compelling and addresses the challenges ahead. It must explain not only why mental health matters, but where solutions will come from and what role governments, clinicians, employers, researchers, funders and innovators each have to play. The field may have to face some uncomfortable questions about whether it wants to be right or effective.

The access movement demonstrated what a shared narrative can achieve. The next phase of progress will depend on finding one again.

That is all for this week. If you enjoyed it or have thoughts on this topic, please do reach out by replying to this email.

Keep fighting the good fight!

Steve

Founder of Hemingway

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