A rambling discourse that started on the meaning of misery and ended on what should mental health treat?

There are many types of pain, suffering and times when an individual says "I am unwell". These are complex and individual experiences. They are not the same for everyone and they do not look the same. Psychiatry and the medical model has developed to say they do look the same and essentially that's what's important.

Depression is the simple example where people experience a range of internal experiences, externalisations and other influences that could by understood as being "depressed". This is poorly recognised in the current definition. It has been observed that men are more likely to externalise their unhappiness in different ways. This may be partially covered by the a diagnosis of atypical depression though the very language shows that it is unusual or not typical when in fact it is simply poorly recognised. This would be even worse in clinical practice where primary care physicans may not be aware of what atypical depression looks like.

A high quality study in the US looked at the experience of people using the DSM-III (or DSM-IIIR) clusters and how often people fitted one or more symptom. The first criteria was a feeling of low or mental unwellness as reported by the individual. There was a surprisingly high number of people who reported this with a slightly higher prevalence in women. As the 8 symptoms that made up the cluster of symptoms (that are clinically signficant when 4 or more are present for a period of time (?2 weeks)) were gradually included the percentages decreased overall and faster in men. This very clearly showed how the cluster approach was 'feminsed' towards acting in symptoms and it also shows that in its question to be scientific it was missing large swathes of people who had the base criteria: a subjective feeling of unwellness.

The diagnostic criteria for depression is a good shot for a poor science. It doesn't cover the heterogeneity of the experience and the human condition, i.e. it thinks that depression is the same for everyone. The cluster system values the individual's report that they are unwell for a period of time but the research criteria ignores some who don't fit the pattern and this may be a large section of the depressed population.

In reality of course it may be quite different. I would expect that the implementation of the diagnostic criteria and the treatment protocols would vary between physicans. Another American study looked at the factor of bias in diagnosis amongst psychiatrists. Surprisingly the bias was not on gender of psychiatrist or patient, ethnicity or age but where the psychiatrists had trained. This is another of many examples of the problem where people will receive different diagnoses from different doctors, something that is much less so but still present in physical medicine.

There is likely a large difference between primary care diagnosis and psychiatrist diagnosis, though again this is likely (but less so) for physical illness. Psychiatric training for primary care physicians was the theme of World Mental Health Day 2009 and the point is a salient one. Better trained GPs who see the majority of people with mental health problems are underequiped to recognise the complexities of emotional and behavioural disorders. However psychiatrists are also poorly equipped by a diagnostic criteria that demands adherence to the cluster of symptoms approach rather than the report of the individual.

The problem of the unusual depression that is experienced without mood effects, e.g. withdrawal without mood fluctuation or usual externalisations, would mean individuals would not report their potential unwellness. This particular idea of depression though is a tricky one where the individual themselves doesn't feel the low of depression which is the most significant cultural definition of depression but exhibits either changes in behaviour, withdrawal or excess giving. It is a question whether this is a form of depression or a socially acceptable way to be depressed from an inner experience point of view. The individual may be unconsciously feeling the roots of where other people feel low feelings. Their externalisations could be based on excessive guilt or clinically low levels of self-esteem. Their behaviour may cause morbidity, changed life course and may reduce their 'flourishingness' (to make a noun of a recent rewording and perhaps reconceptualisation of what is mental health by the Department of Health) and this may be identifable as a prognosis below the average and below their expected life course.

And yet is that something that should be to treated?

I think that's a post for another day.