“I’m fine”: The hidden crisis in youth mental health

“I’m fine.” It sounds harmless, polite even. In my generation though, it has become more than just a phrase. It’s a mask – a default response. A deflection that can delay asking for help and disguise any real distress. I’ve heard it from my closest friends who then disappeared for weeks and strangers who hoped for someone to notice. Some people wear the mask so well that even those closest to them, including me, miss the warning signs. I live in two worlds: one where we study the diagnostic frameworks and another where I see how they constantly fall short for people my age. The gap between how young people experience distress and how healthcare professionals are trained to detect it is alarmingly broad. If we don’t bridge that gap, we will keep overlooking some of the most vulnerable people. Those who suffer silently while thriving on the surface, who then end up falling through the gaps. Mental health screening tends to focus on observable dysfunction such as poor academic performance, behavioural change, suicidality, disordered eating, or self-harm.1 But many young people, especially high achievers, don’t display their distress outwardly. They show up. They smile. They function. And still, they may be struggling with anxiety, depression, self-doubt, or suicidal thoughts. The My World Survey 2, Ireland’s largest study of youth mental health found that only around 20 per cent of young people would seek professional help if they had problems. Despite this, our current systems often triage based on urgency and presentation severity. The unintentional result is that subtle, internalised distress rarely meets the threshold for prompt intervention. If most young people are reluctant to reach out, shouldn’t we be asking why? This reluctance to seek help is shaped by the world we live in, where Gen Z is growing up in a world filled with expectations, both academic and social. Now more than ever, we are becoming fluent in curating our identities, masking difficulties, and staying “on brand.” As a result, emotional vulnerability can feel like a failure to many young people. In schools, students who act out or disengage are more prone to being noticed. However, those who perform well, despite bearing heavy emotional burdens, may never get noticed. In general practice, clinicians are constrained by time and protocol. The PHQ-9 which is widely used as a depression screening tool, helps identify common symptoms. However, it can miss forms of distress that don’t show as appetite loss or overt anhedonia. It doesn’t ask about emotional suppression, social isolation, or the pressure to appear perfect, issues often experienced by young people who are struggling silently. When subtle, internalised distress goes unnoticed, the consequences can be devastating. Suicide stays one of the leading causes of death among Irish adolescents, with hospital presentations for self-harm on the rise.2,3 However, in a study of 16-18 year-olds presenting with mental health crises in Dublin Emergency Departments, nearly half had no previous contact with mental health services.4 The issue isn’t always with the treatment, it’s in detection. A powerful example of this gap didn’t come from a hospital or a public health provider, but from an English football club. In 2023, Norwich City FC published a video titled “Check in on those around you”. It highlighted a seemingly ordinary interaction between two football fans, until a quiet moment revealed the weight one of them was silently carrying. It captured what clinical assessments often miss, the frequently overlooked, performance of “I’m fine.” Ireland needs its own version of this. We have public mental health initiatives, but few that challenge the myth that appearing to function means someone is well. I think it’s imperative to know that distress doesn’t always look dramatic, and that a simple second ask, or a deeper pause, can reveal what standard checklists overlook. The student who is known as the class clown or the teen who is a role model to all. Often, the one who says, “I’m fine” too quickly and too often. It’s time to reframe “I’m fine” as a false negative – a clinical cue that should trigger further open-ended questions. Simple questions like, “When did you last feel okay?” or “Who do you turn to when things get tough?” might seem like small talk but they’re not. For many young people who don’t know how to ask for help, or don’t feel they can, these small moments of genuine curiosity can be the opening they need. If we want to catch what’s masked, we need to start listening differently and looking deeper. That means rethinking how we spot distress in the first place. Let’s begin by recognising the signs at home, amongst friends and integrating signs of high-functioning distress into GP and emergency department triage. Things like emotional suppression, perfectionism, and social isolation. Along with this, medical education needs to be updated so that students learn through real case studies and develop communication skills focused on spotting hidden mental health struggles. I think that public campaigns should shine a light on “masked” mental illness to help reduce shame and encourage people to reach out sooner. In schools, staff should be supported to look beyond just grades or behaviour and really tune into emotional honesty as an important sign of wellbeing. And without a doubt, funding for early intervention services needs to grow because waiting for someone to hit crisis before offering help is simply ‘too late’. Thankfully, those friends of mine who disappeared for weeks managed to pull themselves out of those dark periods. But the truth is, it doesn’t always work out that way. What stuck with me from those moments was that mental health care doesn’t begin with a label or a plan, it starts with just showing up. I realised that listening to what someone doesn’t say it just as important as what they do. If we want to meet young people where they are, we need to look beyond just symptoms and scores. We need to learn that “I’m fine” is not a reassurance but sometimes, the most dangerous lie a young person can tell. So, when did you last feel okay? References: