Dr. Kramer skirts around what is, for my money, the most interesting feature of modern psychiatric medicine: the compression of the normal range. It used to be that we thought that people simply differed -- some melancholy, some choleric, some sanguine, some phlegmatic -- but that nearly everyone was normal.

Now, anyone who differs from a ludicrously precise definition of 'normal' -- one no living, breathing human can possibly match -- is ripe for diagnosis and treatment. One need only present oneself to a mental health professional to get (at least) a borderline diagnosis.

I have noticed this especially with ADD; when my daughter was diagnosed (courtesy of the local elementary school) and I saw how vague the criteria were, I thought that I could get the same diagnosis, as indeed I did. But then I realized that I did not enjoy being around people -- an intensely boring minority -- who were not similarly diagnosable.

The modern definition of 'normal' corresponds to a person who, no matter what the circumstances, never feels either sadness or ecstasy. And that may well be 'normal', but it isn't recognizably human.

Actually, I believe the person who has no feeling would be considered quite abnormal. Also at the time that the four "humours" (choleric, etc.) were popular, doctors were still using leeches to bleed people to treat for fever. Personally, I prefer the medical care we have now.

It might be better to move away from philosophizing over the existence of mental illness and be more pragmatic about it. Vagueness of criteria and other considerations can be debated endlessly, so it may be better to view this in a different way.

In some people who have it, untreated depression progresses to where it's terminal ... i.e. they kill themselves. That this happens is not in question.

The idea that depression is not a pathology, flies in the face of this; it's ridiculous to assume that it is somehow "normal" to be so morose and melancholy as to kill oneself. Another way of putting it: Every suicide that occurs is a tangible demonstration that depression is a pathology and therefore that mental illness is real and needs to be treated.

Any philosophizing which swerves out of the way of this fact, is therefore useless.

I agree with you, ve....vep.....vepapwoieurpqhui­kw.

I recall a med-school coursework book (I won't call it a textbook) on the "social aspects" of medical practice which informed us that (as I recall) "90% of clients visiting a general practitioner should be referred for psychiatric evaluation." I'M NOT KIDDING!

Show a patient to a psychiatrist and a psychiatric diagnosis will ensue! It did less harm back in the voodoo days of talk therapy--but now that there are powerful drugs for a good time (or for masking complaints) there's room for dependancy...and worse.

"Dr. Kramer skirts around what is, for my money, the most interesting feature of modern psychiatric medicine: the compression of the normal range."

One could as easily say "the most interesting feature of modern optometry: the compression of the normal range", but it would sound rather a bit more absurd, wouldn't it? Does anyone think it is sad that optometrists are compressing the normal range of human vision? Not everyone with contacts really *needs* them. Many people are far from blind, and only have mild vision problems. But those irresponsible optometrists are just diagnosing everyone who comes in with "non normal" vision and prescribing contacts like they were candy. Lots of people don't need contacts, they could just hold the newspaper a bit further away from their face or walk a bit closer to that sign they are trying to read. It'll be good for them. It'll build character.


Kolmogorov

StevieN - "90% of clients visiting a GP should be referred for psychiatric evaluation"??? I'd be curious as to what that was based on, because that doesn't make any sense to me - me: "I have a sharp pain in my abdomen" doc: "you need to see a shrink." Ironically, however, part of the problem is that not enough people are being referred for psychiatric evaluation. The reason I say this is that many psychiatric drugs are prescribed by GP's, rather than Pschiatrists. People who go to GPs complaining of depressive symptoms are more likely to be prescribed anti-depressants and less likely to receive psychotherapy than patients who go to a psychiatrist, psychologist, LICSW, or other practitioner. GP's are less likely than mental health practitioners to be fully informed as to medication side effects, or the possibilities of other treatments. Although a psychiatrist is also likely to perscribe meds, they are generally well informed about other treatment options and responsive to patient preferences about medication vs. therapy, etc. However, most insurance plans have limits on therapy visits, or no coverage at all, pushing more patients to the medication route.

There's a lot of comments about how psychiatry has made 'normal' experience a disorder. There may be some of that happening, but really, the key to diagnosing most mental illnesses is that the condition must cause significant impairment to a major life function. So people often like to pull things out of the DSM or say that depression just means sad. But there's a difference between being sad, and being impaired to the point that you have trouble functioning. A proper diagnosis should distinguish that. Also, people often point out that most people who visit a psychiatrist will get a diagnosis and often a prescription. This isn't neccesarily an indictment of the field - for one thing, a clinician assumes that if you go through the hassle of making an appointment, paying a co-pay, getting out of work to come, etc., that you're seeing them because you have a problem that is significant to you. Their first thought is not usually, "is this a person trying to trick me?, or an investigative reporter?", instead, the assumption is that this is a person with issues that are causing them enough distress that they felt a need to seek help for them. Usually they would try to offer help of some kind, rather than say, 'there's nothing wrong, be on your way', essentially discounting their problems. Secondly, and pragmatically, most insurance companies require a diagnosis, even on the first visit, in order to get paid. So, if a clinician wants to stay in business, they are compelled to call the assortment of symptoms presented to them something, even if they're not completely sure about it. So yes, if you have good insurance, and lots of time on your hands, you too, could become one of the "worried well" who fill psychologists waiting rooms across the country. However, I take exception to those who paint the MH field with a broad brush. I have severe depression, and my ability to access the therapy, meds, and other assistance I've needed is what's kept me alive.

At the other end of the spectrum however, things are different. People who are uninsured, or even some with insurance, have a difficult time obtaining mental health care services. The cruel reality also is that severe mental illness tends to leave people unemployed and poor- not only by causing them problems functioning in daily life, but because of the stigma attached to having been in institutions, unexplained work absences, etc. So for the people who need it most, mental health care is often hard to access, despite all the criticism of the field as over-reaching and creating diagnoses for 'normal people'.