Search for a command to run...
A Shared Responsibility Framework for Public Mental Health in the Digital Age The biopsychosocial model assumes the presence of a clinician. In 1977, when Engel published it, this assumption was reasonable. It is no longer structurally sustainable. In England, 549,000 people await ADHD assessment, with some regions reporting waits exceeding ten years. As of 2025, 255,000 children and young people were on waiting lists for community mental health services. In the United States, 169 million people live in designated Mental Health Professional Shortage Areas. Globally, the WHO reports that 71% of people with psychosis receive no treatment. A 2025 survey found that 37% of UK adults had already turned to AI chatbots for mental health support — without clinical governance, without safeguards, and without a structured framework. Patients are not waiting for the system. The question is not whether people will self-assess their mental health in the absence of clinical access. They already are. The question is whether they will do so with structure, safety, and a clear pathway toward professional care — or without any of these things. This paper proposes ADAPT-SHIELD (Shared Health Initiative for Everyday Living in the Digital age): a structured self-assessment framework translating the five domains of the ADAPT model into public-facing guided questions for the pre-clinical period — the space before formal mental health services are reached, termed Step 0. It draws on Self-Determination Theory, patient activation research, digital mental health literacy evidence, and the inverse care law to argue that structured self-assessment represents a plausible, ethically defensible response to workforce scarcity — provided it is deployed with appropriate safeguards and within a shared responsibility architecture. ADAPT-SHIELD is not self-diagnosis, clinical assessment, or treatment. It is designed to increase mental health literacy, prepare individuals for clinical encounters, and scaffold the long period during which professional support is inaccessible. It proposes a three-tier shared responsibility model with defined, non-transferable obligations across individuals, clinicians, and governments — with an explicit prohibition on governments using self-assessment frameworks as justification for reducing clinical investment. The paper addresses the primary harm hypothesis directly: that structured self-assessment may produce false reassurance, reducing rather than scaffolding help-seeking behaviour. This hypothesis generates a specific falsifiable prediction and a prospective stopping rule. Minimum viable safety conditions for any deployment are specified, including an embedded validated distress screener with automatic escalation, operationally defined exclusion criteria, and a 12-week help-seeking follow-up mechanism. The minimum evidentiary standard before wider implementation is stated prospectively. ADAPT-SHIELD requires empirical validation, co-production with people with lived experience, and scrutiny of unintended consequences before implementation. It is a theoretical proposal — and an urgent one.