Why are more and more people being diagnosed with depression?

An In-Depth Look at the Depression Epidemic in Germany

(The original German version of this post can be found here.)

The World Health Organization (WHO) continues to highlight the growing challenges posed by depressive disorders. The core symptoms are, on the one hand, a depressed mood or low spirits and, on the other hand, a lack of motivation and drive. According to the WHO, about 4 percent of the world’s population suffers from this condition, including roughly 6 percent of adults.

Common accompanying symptoms include sleep problems—sleeping too much or too little—and difficulty concentrating. Thoughts of death and even plans or attempts at suicide are among the most severe symptoms. Although suicides are fortunately very rare, they are devastating for those affected and their loved ones. It is known as the “suicide paradox” that although women—who are also more frequently diagnosed with depression—make more suicide attempts, ultimately more men die by suicide in every country in the world. In the U.S., suicide affects four times as many men as women.

The number of suicides (bars) in Germany fluctuates annually between approximately 9,000 and 10,000. The blue line shows the increase in prescriptions for so-called antidepressants over the years. Are you having suicidal thoughts? Helplines or online resources can help. Data sources: Federal Statistical Office, Arzneiverordnungs-Report

Even though depression is a topic everyone is talking about, it is still poorly understood. As I explain in more detail in my book on the depression epidemic, official diagnostic criteria allow for 227 different forms of depression. Yet two people with depression may share as few as one symptom.

Depression, then, has many faces. It is a matter of convention that the problems mentioned are recognized as symptoms, but that ruminative thinking, gastrointestinal problems, or pain—which often occur alongside them—are not: After a couple of years, leading experts gather around the conference table again to agree on the official definition.

An influential British psychiatrist and researcher of the 20th century therefore spoke of “depressive confusion.” By this, however, he did not mean the mental state of those affected, but rather the inability of his colleagues to agree on an understanding of depression—or, in earlier times, melancholy. A German professor I cite in my book described it 120 years ago simply as “pathological sadness.”

Diagnostic Trends

One might think that the 4 percent cited by the WHO is already a significant figure. However, a look at medical practice in Germany reveals a very different picture: According to these figures, a full 38 percent of patients covered by public health insurance were diagnosed with a mental disorder in 2022 . This represents a 13 percent increase compared to 2012. It seems to be becoming increasingly common to have serious mental health issues—and to seek psychotherapeutic and/or medical help for them.

Depression actually topped the list at 14 percent. Women were diagnosed with this condition 1.7 times more often than men. This was followed by mental and behavioral disorders related to psychoactive substances (8 percent). These were diagnosed 1.5 times more often in men. Anxiety disorders ranked third at 7 percent, with women receiving this diagnosis 1.9 times as often. Post-traumatic stress disorder was comparatively rare at 1 percent, but the number of cases doubled compared to 2012 (an increase of 116 percent). Women also received this diagnosis about twice as often.

An analysis of claims data from 68.7 million (2012) and 73.7 million (2022) individuals with statutory health insurance in Germany revealed the prevalence rates for diagnoses shown here. The increase was 31 percent for anxiety disorders, 35 percent for substance use disorders, 15 percent for depression, and 13 percent overall for all recorded mental and behavioral disorders. Data source: Thom et al., 2024, Deutsches Ärzteblatt

But how does this add up: The WHO cites a rate of 4 percent, while in Germany—where 14 percent of the population is diagnosed—the rate is more than three times as high? I’ve already mentioned that there remains some ambiguity about what depression actually is. Beyond the establishment and modification of criteria at the conference table, a much bigger problem arises in practice: How severe do the listed symptoms have to be to justify a diagnosis? For example, how depressed does someone have to be, how often must their sleep be disturbed, how severely must their concentration be impaired, or how often must they think about death?

There is no clear-cut answer to this. The official view is that a diagnosis of a mental disorder typically requires severe distress and/or a significant impairment in daily life. By “severe,” I am translating the technical term “clinical significance.” There are guidelines for what this means. Ultimately, however, it comes down to the clinician’s judgment: If the doctor or psychotherapist believes the problems are serious enough, he or she will make a diagnosis. The system for billing treatment costs also often requires a diagnosis.

Consequences of a Diagnosis

However, this process should not be taken lightly. While a diagnosis of a mental disorder may, on the one hand, open the door to certain treatments, on the other hand, it can backfire in various social contexts—for example, when taking out insurance, applying for a mortgage to buy a home, or considering a potential career as a civil servant.

I myself just had the monthly 3.38-euro “penalty fee” deducted from my mortgage again, simply because I was seeing a psychotherapist due to stress—and I honestly disclosed this to the bank. If you keep it a secret, it could later be interpreted as insurance fraud or some other form of deception and come back to haunt you twofold. Some people who tried this have already had their civil servant status revoked as a result.

Due to long waiting lists—especially for patients covered by public health insurance—a veritable “diagnosis shopping” trend has emerged: For example, a preliminary ADHD evaluation can be purchased for 140 euros; a full evaluation is more likely to cost between 300 and 400 euros. This does not, however, guarantee the desired diagnosis. But who would want to disappoint their paying customers and risk negative reviews?

Many people experience the diagnostic result as a relief: “Finally, I knew what was wrong with me!” In doing so, they not only interpret certain unwanted physical or psychological sensations as a medical problem; rather, they also internalize them. I’ll explain what that means in a moment.

Fortunately, medicine—or rather, clinical psychology—provides not only a diagnosis but, above all, an excuse. “It’s an illness; it’s not your fault!” A discussion of the causes of depression will show that, from a societal perspective, this is no trivial matter. The same applies to most other mental disorders, of which hundreds are now recognized.

History

To better understand this idea, we need to briefly examine the history of psychiatry: In the emerging bourgeois society of the early 19th century, there were two traditional institutions concerned with maintaining normality—the church and the police. However, as urbanization progressed, a growing group of people remained who did not quite fit into these institutions. At the time, these people were called “madmen,” “fools,” or “insane.” They were neither the Lord’s “lost sheep” nor true criminals, even though some of them caused serious problems.

As late as the 1830s, French ministers were still searching for an appropriate, civilized way to deal with these people. The first modern psychiatrists, such as Philippe Pinel (1745–1826) and his favorite student, Jean Étienne Dominique Esquirol (1772–1840), offered the appropriate solution by establishing psychiatric hospitals. The young Sigmund Freud (1856–1939), who would later study under Pinel’s and Esquirol’s later successor, Jean-Martin Charcot (1825–1893), went on to lead psychiatry into the 20th century with his theory of neuroses.

Pioneers such as Pinel and Esquirol established diagnostic systems for „mental illnesses“ and distinguished, for example, between dementia, mania, melancholia, and „idiotism.“ They compiled statistics on their prevalence and developed theories about their causes and treatments.

From Observation to the Brain

Above all, however, psychiatry needed a suitable organ that could serve as the source of the illness. It feared that, otherwise, it would not be taken as seriously as other fields of medicine. At the time, phrenology was in vogue, and its view of the brain’s functional specialization was ultimately adopted by psychiatrists—but without acknowledging the folkloric aspects of the study of skulls, namely the later-discredited notion that one could infer a person’s character from the shape of their head.

The idea that psychiatry is essentially the study of the diseased brain continues to shape research and practice in this discipline to this day. In the case of syphilis—a sexually transmitted disease that was still untreatable at the time—this was often true: Over time, the bacterium Treponema pallidum caused increasingly severe damage, in many cases extending to the nervous system. This led to the dreaded “neurosyphilis,” which, in addition to neurological disturbances in perception, movement, and speech, could also result in the psychiatric condition known as “delusion.” And because its symptoms resembled those of so-called schizophrenia, a neural cause was also suspected here and for the other clinical presentations.

However, this neuropsychiatric dream has yet to come true. Psychological and psychiatric diagnoses are still made through interviews and behavioral observation. There is no reliable genetic or brain test for any of the hundreds of disorder classifications. The alleged genetic contribution to the development of these problems is regularly exaggerated. Yet in the 1970s, the goal was to move away from Freud’s model and finally create the long-awaited new, scientific, and objective psychiatry.

Just recently, leading experts outlined plans for the next revision of the diagnostic system, which is expected to be completed sometime in the 2030s: At the top of the list are still a neuroscientifically grounded classification of diseases and biological tests for these disorders. This is expected to be possible soon for Alzheimer’s. We’ll see. In any case, this highlights the significant knowledge gap regarding brain function in psychiatry.

Risk Factors

What remains in the meantime? A vague clinical picture of depression. An inexplicable rise in diagnoses. A field of psychiatry—and, to some extent, clinical psychology—that aspires to be objective neuroscience but has failed to achieve this for 200 years. It is therefore more accurate to speak not of the “causes” of mental disorders, but of “risk factors.” And according to decades of research, these are found primarily in the psychosocial realm.

As I explain in more detail in my book on the depression epidemic —and as the WHO also confirms—these are primarily major life events in the case of depressive disorders. These include, for example, unemployment, the loss of a relationship due to separation or death, and traumatic experiences—such as those in childhood, as a victim of an accident or crime, or during military or crisis deployments. It is generally recognized that severe, prolonged stress increases the likelihood of many mental and physical health problems. In this sense, experiences of prolonged poverty or social exclusion can also take a toll on one’s mental well-being.

Severe substance abuse is another risk factor. However, psychoactive substances are often used as a means of coping with a difficult life; thus, the direction of the cause-and-effect relationship is not entirely clear in this context. Numerous scientific studies from various countries have confirmed that experiencing childhood abuse increases the risk of heavy alcohol and other drug use, depression, and suicide many times over. And emigration—or, even more so, involuntary flight—to a different culture significantly increases the likelihood of a schizophrenia diagnosis.

Internal Conflict

This brings us to the internal conflict that continues to plague psychiatry to this day. It strives to be as objective and scientific as the other branches of medicine. To that end, it introduced the brain model as early as the 19th century. However, those affected still suffer from its consequences today: By effectively expelling the psyche—the soul, so to speak—from psychiatry (literally: soul medicine) and attempting to transform it into what we would now call “clinical neuroscience,” it was torn from its foundations. Even in Freud’s teachings, mental disorders often stemmed from unconscious psychological processes.

Without proper recognition, many people affected still find that their problems are downplayed, trivialized, or even completely denied as being „psychological“ or „psychosomatic.“ One reader once put it aptly in a discussion about chronic fatigue syndrome (CFS): “No, this isn’t psychological—it’s real!”

When the psychological—our most intimate inner self—is dismissed as an illusion, then humanity’s alienation from itself is complete. As a result, people give even those who are visibly suffering from severe depression useless and humiliating advice, such as “Don’t be such a drama queen!” or “Why don’t you take a vacation?”, if they don’t simply label them as lazy or malingerers outright.

There would be advantages if neuropsychiatry had lived up to its promise and if the clinical pictures of disorders could be diagnosed, for example, using brain scans: Then it would not be possible for the WHO to estimate the prevalence of depression, for example, at 4 percent of the population, while in 2022—as we saw above—14 percent of the population in Germany received that diagnosis. The latest figures from the Robert Koch Institute even suggest a rate of 22 percent, though they used different criteria for this calculation.

In practice, professionals see large numbers of people with nonspecific problems such as exhaustion, fatigue, low mood, listlessness, and perhaps sleep problems or weight changes. Added to this is an almost endless array of other mental and physical symptoms for which there is no clear medical explanation. Many professionals then suspect a depressive disorder and diagnose it accordingly. In psychotherapy—assuming one can even secure a spot—problematic thought patterns, unconscious conflicts, and/or relationship dynamics can be addressed, depending on the therapeutic approach.

Individualization

The catch, however, is this: Both psychiatry’s model of the brain and conventional psychotherapy methods treat problems as individual issues. Yet we’ve seen that risk factors often lie in the environment and in past experiences. If all you have is a hammer, every problem looks like a nail. And if you only see a person for a short time and in private within the isolated setting of a practice or clinic, the most obvious starting point is, of course, that individual. You generally don’t see their normal, everyday, family, and work environments.

There is much more to be said about the rise in psychological and psychiatric diagnoses—whose annual incidence was estimated above at 38 percent, and which is on the rise. But let us conclude here by pointing out a therapeutic dilemma: Social hardships are increasingly being psychologized, psychiatrized, and medicalized. Yet it is impossible to provide psychotherapeutic care for this vast number of people, even though we have more therapists today than ever before. I myself have trained thousands of people academically in the field of psychology.

Such an increase can only be managed if therapeutic measures can also be scaled up accordingly. This is where psychotropic drugs come into play, which—unlike therapists—can be mass-produced. Consistent with the aforementioned rise in diagnosed depression—now at 14 percent or more per year—general practitioners are increasingly prescribing the (supposedly) appropriate medications themselves and are less likely to refer patients to psychiatric specialists. These are the so-called antidepressants, which are now prescribed eleven times as often as they were 35 years ago.

Of the so-called antidepressants—primarily serotonin and norepinephrine reuptake inhibitors—1.8 billion daily doses are now prescribed each year in Germany. That is enough to treat approximately 5 million people daily. Data source: Arzneiverordnungs-Report

In the second part, we’ll discuss the effects and side effects associated with this, as well as what it might mean for those affected.

More on the Depression Epidemic

Learn more about mental disorders in Stephan Schleim’s new book: What exactly is depression and how is it diagnosed? Why are diagnoses and prescriptions constantly rising? The 27 chapters cover fundamental and current topics. Order the German book, packed with information and numerous illustrations, now for just €19.95 from the BoD Shop. Or get the eBook for just €9.99 from Amazon, Apple Books, and Google Play Books.

Sources

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• Oquendo, M. A., Abi-Dargham, A., Alpert, J. E., Benton, T. D., Clarke, D. E., Compton, W. M., … & Gogtay, N. (2026). Initial strategy for the future of DSM. American Journal of Psychiatry, 183(5), 292-300.
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• Schleim, S. (2026). Perspektiven aus der Depressions-Epidemie: Was Depressionen sind und wie man sie behandelt. BoD, Hamburg.
• Thom, J. et al. Dtsch Arztebl Int 2024; 121: 355-62; DOI: 10.3238/arztebl.m2024.0052
• Zeiss, R., Malejko, K., Connemann, B., Gahr, M., Durner, V., & Graf, H. (2024). Sexual dysfunction induced by Antidepressants—A pharmacovigilance study using data from vigibasetm. Pharmaceuticals, 17(7), 826.

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