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America’s Top Export May Be Anxiety

English-speaking teens are spreading their problems abroad.

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T he argument that smartphones and social media are contributing to the rise in teen mental distress is strong. A number of observational and experimental studies show that teen anxiety started rising just as smartphones, social media, and front-facing cameras contributed to a wave of negative emotionality that seems to be sweeping the world.

But I have one small reason to question the strongest version of the smartphone thesis. You can find a summary of it on page 5 of this year’s World Happiness Report , a survey of thousands of people across more than 140 countries. “Between 2006 and 2023, happiness among Americans under 30 in the U.S., Canada, Australia, and New Zealand declined significantly [and] also declined in Western Europe,” the report says. But here’s the catch: In the rest of the world, under-30 happiness mostly increased in this period. “Happiness at every age has risen sharply in Central and Eastern Europe,” the report says. “In the former Soviet Union and East Asia too there have been large increases in happiness at every age.”

This is pretty weird. Smartphones are a global phenomenon. But apparently the rise in youth anxiety is not. In some of the largest and most trusted surveys, it appears to be largely occurring in the United States, Great Britain, Canada, Australia, and New Zealand. “If you’re looking for something that’s special about the countries where youth unhappiness is rising, they’re mostly Western developed countries,” says John Helliwell, an economics professor at the University of British Columbia and a co-author of the World Happiness Report. “And for the most part, they are countries that speak English.”

The story is even more striking when you look at the most objective measures of teen distress: suicide and self-harm. Suicides have clearly increased in the U.S. and the U.K. Emergency-room visits for suicide attempts and self-harm have been skyrocketing for Gen Z girls across the Anglosphere in the past decade, including in Australia and New Zealand. But there is no rise in suicide or self-harm attempts in similar high-income countries with other national languages, such as France, Germany, and Italy. As Vox ’s Eric Levitz wrote , the suicide rate among people ages 15 to 19 actually fell significantly across continental Europe from 2012 to 2019.

Happiness is a notoriously difficult thing to measure. So I asked Helliwell for more data. He suggested we look more closely at his home country of Canada, which has two official languages—French and English. In Quebec, more than 80 percent of the population speaks French; in neighboring Ontario, less than 4 percent of the population speaks French. Quebec seems like a perfect place to test the question “Is mental health declining less among young non-English speakers?”

The answer seems to be yes. In Gallup data used for the World Happiness Report, life satisfaction for people under 30 in Quebec fell half as much as it did for people in the rest of Canada, Helliwell told me. In a separate analysis of Canada’s General Social Survey, which asks respondents about their preferred language, researchers at the University of British Columbia and the University of Alberta found that young people who speak French at home saw a smaller decline in happiness than those who speak English at home.

Jonathan Haidt: The dangerous experiment on teen girls

So youth in English-speaking Canada are becoming sadder faster than those in French-speaking Canada, and measures of teen suicidality are rising in the Anglosphere but less so in similar less-English-speaking countries.

What’s the deal with Anglosphere despair? Maybe this is a statistical illusion that will evaporate with more research. Maybe speaking English is a rough proxy for economic development, and this is mostly about affluent countries with lots of teen smartphone use. I couldn’t find any papers on the subject of why language would correlate with mental health for teenagers. Helliwell, a renowned expert of international happiness research, didn’t know of any comprehensive analysis on the subject either.

But after several conversations with happiness experts and psychologists, I’ve cobbled together a tentative theory. We’re seeing the international transmission of a novel Western theory of mental health. It’s the globalization of Western—and, just maybe, American —despair.

I n the past few years , at least three distinct phenomena have potentially contributed to the gloom of the Anglosphere. Let’s think of them as diagnostic inflation, prevalence inflation, and negativity inflation.

First, the diagnostics. In 2013, the psychiatrist Allen Frances offered a warning to his field. Frances had chaired the American Psychiatric Association during revisions of the fourth edition of psychiatry’s “bible,” the Diagnostic and Statistical Manual of Mental Disorders , commonly known as DSM-IV . The first edition of the DSM — published in 1952 in response to the needs of military personnel returning from World War II—listed about 100 mental disorders. By 2013, the number of disorders listed in the DSM had swelled to nearly 300. In his 2013 book, Saving Normal , Frances warned that “a looser definition of sickness” could make people worse off. “DSM-V opens up the possibility that millions and millions of people currently considered normal will be diagnosed as having a mental disorder,” he told the Canadian Medical Association Journal that year. The expansion of clinical vocabulary risked creating a new set of patients he called the “worried well”—people with normal human experiences who spent a lot of time worrying that they have a disorder. He and others called this phenomenon “diagnostic inflation”—the slapping-on of more (and more, and more) clinical labels to pathologize everyday sadness and stress.

Frances was mostly concerned that diagnostic inflation would lead to over-medicalization. He might have been right. By 2016, the share of people in the U.S. using antidepressants was more than twice as high as in Spain, France, or Germany, and nine times higher than in South Korea.

As our mental-health lexicon has expanded, U.S. content creators have recognized that anxiety is a hugely popular—or, at least, hugely attention-grabbing—topic for young people scrolling on their phones. As I reported in December, the TikTok hashtag #Trauma has more than 6 billion views. According to the podcast search engine Listen Notes, more than 5,500 podcasts have the word trauma in their title. In celebrity media, mental-health testimonials are so common that they’ve spawned a subgenre of summaries of celebrity mental-health testimonials, including “39 Celebrities Who Have Opened Up About Mental Health,” “What 22 Celebrities Have Said About Having Depression,” and “12 Times Famous Men Got Real About Mental Health.”

This takes us from diagnostic inflation to “prevalence inflation,” the term psychologists Lucy Foulkes and Jack L. Andrews use to describe the phenomenon of people developing apparent anxiety disorders from the sheer ubiquity of concern about anxiety disorders that swirl all around them. It might work something like this: People who keep hearing about new mental-health terminology—from their friends, from their family, from social-media influencers—start processing normal levels of anxiety as perilous signs of their own pathology. “If people are repeatedly told that mental health problems are common and that they might experience them … they might start to interpret any negative thoughts and feelings through this lens,” Foulkes and Andrews wrote . This can create a self-fulfilling spiral: More anxiety diagnoses lead to more hypervigilance among young people about their anxiety, which leads to more withdrawal from everyday activities, which creates actual anxiety and depression, which leads to more diagnoses, and so on.

To be clear, bringing anxiety and depression out of the shadows has been a societal mitzvah for many. Twentieth-century cultural touchstones such as The Deer Hunter and Revolutionary Road remind us that adults have long suffered from PTSD and depression in shame and silence. Nobody should want to bring back these postwar mental-health norms. But there is a difference between destigmatizing mental-health problems and popularizing them to the point that millions of young people are searching their normal feelings for signs of disorders.

Finally, as diagnostic inflation and prevalence inflation combined to raise the salience of our neuroses, something else was happening behind the scenes. The general tenor of America’s political and economic news discourse got much more negative in a very short period of time. To match diagnostic and prevalence inflation, let’s call this negativity inflation.

Last year, researchers at the University of Pennsylvania, Indiana University, and London Business School used machine learning to scan text from hundreds of millions of pages, from thousands of American newspapers in all 50 states, from the 1850s to the 2020s. They tracked the frequency of positive words ( success , optimistic , upbeat ) and negative words ( failure , insolvent , loss ) through dozens of recessions, several panics, and a few major wars. “For a very long period of time, our index of negativity in American news articles fluctuated around a stable average,” the UPenn economist J. H. van Binsbergen, a co-author on the paper, told me. But since the 1970s, negativity has gone haywire. “News coverage has just gotten more and more negative every decade in the last 50 years, especially when you adjust for economic recessions,” he said. Around 2015, the frequency of negative news coverage accelerated. By 2019 and 2020, the average sentiment of American news was more negative than ever.

How did the news get so glum? One possibility is that the media industry has become more competitive in the past few decades, as newspapers struggled to compete with cable news for viewership—and then with websites and digital platforms for advertising. As publishers became desperate to capture distracted audiences, more of them doubled down on that ancient truism: Bad news sells. In the 2001 paper “ Bad Is Stronger Than Good ,” psychologists from Case Western Reserve University and Free University of Amsterdam wrote that bad emotions might naturally grab our attention and persist in our memory, because it is “evolutionarily adaptive” for intelligent animals to focus more on stimuli that threaten their safety. The internet has supercharged this hominid instinct, the NYU psychologist Jay Van Bavel told me in an interview on my podcast, Plain English . The title of a 2023 paper that he co-authored says it all: “ Negativity Drives Online News Consumption .”

Put it all together—diagnostic inflation in medicine; prevalence inflation in media; negativity inflation in news—and one gets the distinct sense that Americans might be making themselves sick with pessimism, anxiety, and gloom. But that’s not all. Just as the U.S. has long been the global economy’s chief cultural exporter—from Coca-Cola to Mickey Mouse—it’s conceivable that we are disseminating throughout the English-speaking world a highly neurotic and individualistic approach to mental health, which is raising the salience of anxiety and depression for young people spending hours every day marinating in English-speaking media.

I n his book Crazy Like Us: The Globalization of the American Psyche , Ethan Watters offers a fascinating provocation: As Americans export their culture around the world, are we also exporting our ideas about mental illness, anxiety, and depression?

Watters begins by reminding us that mental illness has historically been localized and diverse. For centuries in Malaysia and Indonesia, men were said to experience amok if, after periods of brooding following an insult, they launched into a murderous rage. In parts of Asia and Africa, koro anxiety referred to the debilitating worry that one’s genitals were shrinking or retracting into one’s body. In Victorian Europe, thousands of affluent women in the era claimed they couldn’t get out of bed, because of the onset of “hysterical leg paralysis,” while many young men suffered from “hysterical fugue”—a trance in which they would walk for hundreds of miles for no particular reason.

But globalization and the internet may be flattening the world’s once spiky terrain of mental disorders, Watters claims. His most striking example comes from Hong Kong, where psychiatrists tell him that, for centuries, there was practically no record of anybody suffering from anorexia in the city-state. That changed in 1994, when a young girl died of apparent starvation in the middle of a busy street in front of news cameras, causing a national panic. Mental-health experts from the West arrived to offer an explanation: This was anorexia nervosa—self-starvation. On TV and in schools, these experts explained how young girls with extreme stress or depression might be susceptible to this new disease. Within a decade, anorexia rates in Hong Kong skyrocketed by orders of magnitude.

A simplistic explanation of Hong Kong’s anorexia surge—along with koro and hysterical fugue—would be that mental illness is always and everywhere a case of social contagion. That’s wrong. What we call worry and sadness are universal human traits, and many psychiatric disorders, such as schizophrenia, show up around the world. Watters’s most interesting idea is more subtle: Negative thoughts and feelings whisper to us from the subconscious. To make sense of our darkest thoughts, we may pull concepts off the shelf—grabbing whatever’s circulating in our local culture at that time—to articulate and act out our bad feelings.

Meghan O’Rourke: Hypochondria never dies

“Patients unconsciously endeavor to produce symptoms that will correspond to the medical diagnostics of the time,” one mental-health expert tells Watters. So if you grow up in a 19th-century environment where you are told that stressed people don’t get out of bed, you might not get out of bed , and your doctors might diagnose you with hysterical leg paralysis . And if you grow up in a 21st-century culture in which your phone keeps lighting up with high-arousal negativity, you might explain the inchoate worried gloom you experience on the internet in the patois of the times: I’m sick; I have trauma; this is my disorder. If Watters is right, it’s not outlandish to think that an individualistic, made-in-America approach to mental health—which promotes a kind of obsessive fixation on our traumas and anxieties—might be spreading throughout the English-speaking world, like any bit of culture.

T his is a novel hypothesis —which, almost by definition, doesn’t have nearly enough data behind it to count as an empirical theory. To reiterate, the “anxiety inflation” hypothesis has four parts.

• Diagnostic inflation : The U.S. psychiatric community offered an expansive definition of sickness, which carried the risk of creating a huge population of “worried well” patients who pathologized their normal feelings.
• Prevalence inflation : As teens surrounded themselves with anxiety content on the internet, many vulnerable young people essentially internalized the pathologies they saw over and over and over in the media.
• Negativity inflation : Meanwhile, a surge in negativity across American news media deepened the baseline feeling of world-weariness
• Globalization of the American psyche : The U.S., the world’s leading cultural-export power, is broadcasting this mental-health ideology, this anxious style of self-regard, to the rest of the English-speaking world. This has happened before. But rather than spread the word through expert mental-health campaigns (as anorexia may have spread in Hong Kong in the 1990s) this “anxiety inflation” disorder is also spreading peer-to-peer and influencer-to-influencer on social media. This is why smartphone use and anxiety seem to correlate so highly in English-speaking countries, but less so in countries and areas that are not as exposed to American media.

I don’t want to let smartphones and social media off the hook here, nor do I think that my anxiety-inflation theory is a strong objection to Jonathan Haidt’s thesis in The Anxious Generation . Haidt himself has written about the content young people consume on social media, including the rise of a “reverse-CBT” ideology, which encourages catastrophic interpretations of normal thoughts and feelings. But I think we need to deal head-on with a real empirical mystery here: If smartphone use is global, why is the strongest evidence of surging teen anxiety mostly in English-speaking countries and not in their less-English-speaking neighbors?

My answer is that although mental illness is global, the experience of mental illness cannot be separated from culture. If there is a surge of Anglospheric gloom among teenagers, we have to study the culture that young people are consuming with their technology. In the past generation, the English-speaking world, led by the U.S., has experimented with a novel approach to mental health that has expanded the ranks of the “worried well,” while social media has surrounded young people with reminders to obsess over their anxieties and traumas, just as U.S. news media have inundated audiences with negativity to capture their fleeting attention.