Javier José Pérez Flores
Professor in the Department of Psychobiology at the University of La Laguna
The study has one clear strength: it uses a very large sample and a time span long enough to detect relevant epidemiological trends. This type of design makes it possible to observe changes in how mental health issues are referred to primary care and recorded in health care systems. However, precisely because of the breadth of the data, caution is warranted in interpreting the results. What the study shows is not necessarily a direct change in the actual prevalence of mental disorders, but rather a change in the way certain psychological problems are recorded, coded, and possibly addressed within the Norwegian healthcare system.
The first important point is that these findings are not new in this field of study. The discrepancy between the prevalence of symptoms and the prevalence of diagnoses had already been noted over the past decade. A clear example is the work by Archer et al., published in 2022, which described a very similar trend in the United Kingdom regarding anxiety symptoms. There, too, an increase in symptom-related records was observed, without this automatically translating into an equivalent increase in formal diagnoses of mental disorders.
This distinction is fundamental. In the case of the Norwegian study, what the data seem to reflect is that, between 2010 and 2024, the increase in mental health contacts in primary care is concentrated primarily in records of anxiety and depression symptoms. In contrast, the codes corresponding to disorders increase much less or remain relatively stable. That is, strictly speaking, the conclusion supported by the data. Any additional interpretation (for example, that there is more suffering but not more disorders, or that diagnoses are declining) requires much greater caution.
In fact, the study by Archer and colleagues itself helps explain why. That study included interviews with physicians, and some professionals noted that they preferred to code symptoms rather than disorders to reduce the stigma associated with psychiatric diagnosis. This raises the possibility that the increase in symptom coding does not necessarily mean there are fewer diagnosable cases, but rather that professionals are choosing to label these problems differently. In other words, part of the phenomenon could stem from coding practices.
Something similar occurs when interpreting the study from a public policy perspective. At first glance, it might seem that these results call for a fundamental rethinking of how mental health care is organized. However, they can also be interpreted as the result of health policies already in place in Norway. In 2012, the country implemented a reform that granted municipalities greater autonomy in the provision of health services, reinforcing a model more heavily reliant on primary care and community resources.
This approach aligns with the Escalation Plan for Mental Health 2023–2033, which explicitly addresses the need to lower the threshold for receiving help and to prioritize municipal services over a model that is overly focused on specialized care. The plan itself acknowledges that many people with mental health issues are already in contact with their family doctor and includes interventions such as supportive conversations, stress management courses, or brief treatments for mild forms of anxiety and depression. In other words, the Norwegian system appears to recognize a middle ground between psychological distress and a formally diagnosed mental disorder.
The Prompt Mental Health Care program, launched as a pilot in 2012, should also be viewed in this context; it is specifically designed to provide psychological treatment in primary care for mild or moderate symptoms of anxiety and depression. Viewed in this light, the increase in reported symptoms need not be interpreted solely as an epidemiological warning sign, but also as a reflection of an organizational decision: to identify distress earlier, address it in more accessible settings, and not necessarily wait for it to take the form of a fully coded disorder.
Therefore, I do not believe it can be concluded that there are fewer diagnoses in Norway despite more reported symptoms. Rather, what we see is a combination of changes in professional coding, expanded access to primary care, and the choice of specific approaches to addressing psychological distress. Whether this is positive or negative is another matter. To assess this, we would need to analyze whether these individuals receive adequate care, whether severe cases are referred appropriately, whether unnecessary medicalization is avoided, or whether, on the contrary, problems that would require more specialized intervention are trivialized.
The comparison with Spain also calls for caution. We do not have a point-by-point equivalent study, but the Ministry of Health’s report Mental Health in Data highlights two relevant points. The first is that the coding method significantly alters the recorded prevalence of disorders. The second is that the difference between recording symptoms and recording disorders produces patterns that resemble, at least partially, those observed in the Norwegian study. This suggests that administrative figures not only indicate how many people suffer from certain problems but also how decisions are made regarding their classification.
One final piece of data sheds light on the issue from another angle. Anmella and colleagues analyzed antidepressant prescriptions in primary care in Catalonia between 2010 and 2019 and found a very sharp increase in antidepressant prescriptions, far exceeding the rise in depression diagnoses. This type of finding raises an uncomfortable question: To what extent does it matter that the system codes symptoms or disorders if, in practice, the approach ends up being the same?
That is, probably, the underlying issue. The debate should not be limited to whether symptoms are increasing or diagnoses are increasing, but rather to what is done for people who come to primary care with psychological distress. If symptoms are coded to reduce stigma, facilitate access, and provide appropriate brief interventions, it may be a reasonable strategy. If, on the other hand, symptoms are coded but the response is always the same pharmacological approach or insufficient care, the change in terminology adds little.