Normal but Not Detectably Sane

Woman looking out window

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Hamlet’s question, “To be or not to be,” has been a meme since it was first uttered on an Elizabethan stage. That’s because being—existence—involves suffering. Life is hard. That truth centers much on human art, faith, and philosophy.

The reality of suffering doesn’t lessen the darkness of real depression. But it complicates the question of how to measure the normal despair, which philosopher Jean-Paul Sartre claimed life begins on the other side of. I wrote recently that I got diagnosed as mildly depressed by an online depression screening, though I was both honest in my answers and happy. The results page suggested I see my doctor.

Interested, I’ve taken two more online depression tests. Both ranked me mildly depressed and at the end of one, a chatbox popped up with a live person waiting “to talk.”

Is mental wellness detectable among the ordinary trials of ordinary life? And when surrounded by so much easily dispensed medication? In 1969, a psychologist named David Rosenhan entered a psychiatric institution called Haverford to test psychiatry’s ability to diagnose the well. Rosenhan published the results in the journal Science. His article “On Being Sane in Insane Places” begins, “If sanity and insanity exist, how shall we know them?”

How shall we?! My depression tests consisted of 10 to 13 questions. Each test ranked whether I’d been “bothered by” various states over the past two weeks on a scale of “not at all,” on “several days,” “more than half the days,” or “nearly every day.” Symptoms included things like feeling down, depressed, or hopeless; poor appetite or over-eating; tiredness; trouble falling asleep or sleeping too much. There was no sense of whether to be “bothered” by something would mean for a long time or briefly. One test asked whether I’d had any physical aches and pains.

Obviously, there’s an astonishing amount of white space around these questions. Feeling down at some point one day per week seems very human. And it says nothing about the rest of the time. Arguments, time changes, spats, holidays, the news—surely any two-week period holds challenges to sleep, eating or perceptions about eating, and self-worth.

I don’t get much help diagnosing wellness from the DSM-5, the Diagnostic and Statistical Manual of Mental Disorders, the basis of our current practice. Most DSM categories—and there are hundreds—have master symptom lists with an “any three out of the following seven”-type standard. Symptoms for a bipolar hypomanic episode include flights of ideas, “increase in goal-directed activity”—isn’t that a good thing?—and decreased need for sleep. For diagnosis, these three would occur within a “distinct period” of at least four days featuring expansive mood and increased activity or energy.

The poet Rilke wrote of his intense work, “Heaven knows what nourished me.” Writing the Duino Elegies at the Castle Duino, he “forgot to eat and sleep.” Many artists and researchers have peak periods. But I imagine a four-day span of increased work and ideas happens to everyone. Planning a wedding or bar or bat mitzvah, studying for a major test, and getting involved in a game or even a Wordle binge also feel very human.

Who judges whether the “goal” in question is real? As a writer diagnosed with bipolar disorder, I’ve had to defend my work as meaningful, not imaginary (or, the DSM would say, “grandiose”). Most of us aren’t upper-crust male poets who write in castles borrowed from their friends, which I imagine earned Rilke a little cred. Gender, race, sexuality, and social class—all affect how real, and therefore healthy, a “goal-oriented activity” would be clinically viewed. Someone who doesn’t fit a clinician’s idea of an artist will find Rilke’s intensity looks like something very different in their psych workup.

The autism section of the DSM notes those on the spectrum may not understand why people tell white lies, as if lying makes such intrinsic sense it’s a symptom of wellness.

Rosenhan got admitted to Haverford by claiming to hear voices saying the words “hollow,” “empty,” and “thud.” Otherwise, he presented as “normal”: a successful and content professional, spouse, and parent. He was diagnosed with schizophrenia. Rosenhan’s story matters for many reasons—he found patients dehumanized, even brutalized. That our institutions often still operate at this level is a national crime.

Rosenhan’s work also illustrates a philosophical question: Could clinicians, symptom lists in front of them, find clear differences between sick and well? Could they look at a healthy, functioning person and just send them home?

A subhead in Rosenhan’s paper reads less Science than The Onion: “The Normal Are Not Detectably Sane.”

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Many people taking my tests would see a doctor and get antidepressants in visits too brief to get into that white space, the questions around the questions. These are medications that have a high placebo rate and, as medications go, slim rates of effectiveness. Antidepressants are hard to withdraw from. I know people have been helped by them, but prescribing an antidepressant is not like putting someone on a course of aspirin.

A criticism lobbed at Rosenhan is that he brought himself to Haverford and asked doctors about the voices—you could assume they bothered him. But we live in a culture where advice columnists tell letter writers to get family members “assessed,” people chronically armchair-diagnose, and there’s pressure for annual depression or anxiety screening questions for everyone.

A psychiatrist named Gerald Klerman, who worked on the DSM, declared a “discrete” line exists between the mentally ill and mentally well and that this is one of the premises of biological psychiatry. “Discreet,” as in hard to see, might have been the better spelling.

“The sane are not ‘sane’ all of the time,” Rosenhan noted. They get angry, sad, and anxious, normal emotions he described and then found exaggerated in his clinical notes at Haverford.

“If patients were powerful rather than powerless,” Rosenhan wrote of his dismal time as a psychiatric patient, “if they were viewed as interesting individuals rather than diagnostic entities . . . would we not seek contact with them, despite the availability of medications?” Contact. Not lists. And this is how we shall know them.