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Psychic suffering has increased, even as more of the population receives care.

Some help: Social prescribing, less faith in the DSM, and understanding neurodiversity

Medicine often loves a good bout of cockeyed optimism. Psychiatry’s latest came in the latter twentieth century. A review in the Lancet calls it a time when “it seemed that even the most intractable conditions like schizophrenia would yield their genetic and biochemical secrets and thereby offer targets for drug intervention.”

But there’s been little yielding.

Mental distress isn’t and never will be “a disease like any other.” Depression doesn’t come from “brain chemistry,” and the idea of lifelong drug treatment would have bothered practitioners living in the time of Hippocrates—400 BC. Psychic suffering has increased, even as more of the population receives care.

Distress is complex, involving trauma, things happening to and in the body, and a FOMO-filled, inequitable, and stressful world.

But much psychiatric training, and public awareness about psychiatry, focuses on biology. Psychiatrists begin their career with an M.D. degree before doing residencies in the field. Media pieces about mind care still focus on biological solutions.

The Greek Hippocrates created the longest-running theory of depression, one that influenced treatment well into the 1700s. Hippocrates believed what he called “melancholy” came from an overabundance--of an imaginary substance called black bile.

So the question about mind care isn’t whether it exists, but how to approach it. The field has moved beyond Renaissance prescriptions to combat bile by shunning the meat of the hare. But to where, exactly?

My friend Roger Jou, a psychiatrist who co-directs Cultural Autism Studies at Yale (CASY), told me that to perform as beautifully as he does in that role, he’s had to unlearn much of what he was taught. I’ve heard that from many others in the field--lessons on brain function don’t translate to the complexities of human minds and hearts.

I’ve been wondering lately what changes might improve psychiatric education, for doctors and, equally important, for patients. (And I’ll be returning to this subject again.)

I posed that question to Jou. For this post, I also spoke to Julia Hotz, author of a book about social prescribing titled The Connection Cure. Here are some thoughts:

The DSM and ICD: In the U.S. the DSM (Diagnostic and Statistical Manual of Mental Disorders) serves as the source for diagnostics and insurance reimbursement. The ICD (International Classification of Diseases) is an international version.

“It’s important to address the history of these texts, how they were developed, evolved, and continue to be used,” Jou says. “These are created by people and not some fundamental biological truth, so their use has significant limitations.” Our psychiatric labels are “a human-created system to try to wrap our heads around the complexities of the human mind and brain.”

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I want to underscore the phrase “not biological truth.” No lab results ever showed things like low serotonin in the depressed; there’s no blood test for ADHD. Many drugs work without medicine understanding how. But psych meds, which are tied to DSM diagnoses, perform with what even those who defend them call “moderate-to-weak efficacy.” Some studies show that antidepressants don’t beat placebos, which can strongly impact depression.

I’d love to see the DSM revised along a patient-centered, trialogue model using only doctors with no pharmaceutical ties--a huge problem with the last revision. Or discarded.

Education in neurodiversity. “This should be foundational with clear understanding that different does not mean pathology,” says Jou. “In fact, our differences are how we thrive as a species.”

Jou adds, “There’s a lot of binaries in medicine. Someone has cancer or they don’t. This doesn't always carry over smoothly to mental health. Human minds and brains are so very different—we need stronger understanding and acceptance of neurodiversity.”

Many societies have accepted, and still accept, a much wider range of behaviors than we’d now consider “normal.” The poet William Blake greeted friends while sitting naked in a tree, pretending to be Adam. Nikola Tesla had a thing for the number three—he walked around buildings three times and his hotel rooms had to be multiples of three. People accepted the behaviors as differences related to who the men were as individuals, not illnesses.

Social Prescribing. When I worked as a medical writer, I often heard doctors mutter that such-and-such a patient “really needs a day at the beach.” Doctors now might train to put beaches into their prescriptions. In social prescribing, in Julia Hotz’s words, “a patient is referred to a non-medical, community-based activity, aligned with their needs and interests. Typically, prescribed activities involve movement, nature, art, service, and belonging, all associated with improvements in health and well-being.” Yoga and most exercise, even some self-help modalities, can work as well as anti-depressants.

The UK has adopted social prescribing more enthusiastically than the U.S. has. Hotz reports that UK pilot programs have shown “improvements in patients’ mood, self-esteem, well-being, physical activity, and social connectedness, as well as reductions in loneliness, stress, and anxiety. Other studies find social prescribing eases pressure on healthcare systems.”

Back to that optimism: Peter Kramer’s Listening to Prozac, published in 1993, argued that antidepressants could make many of us “better than well.” The subtitle, A Psychiatrist Explores Antidepressant Drugs and the Remaking of the Self, teases his argument: The drugs are so effective that users could essentially become different beings. He thought that antidepressants could have this effect even on the undepressed, enhancing qualities from business acuity to sex appeal.

Kramer worried that our future might be a society of people enhanced with culturally valued qualities by their medication—he called it “cosmetic pharmacology”—but not really themselves.

Now, in 2026, more than 11% of Americans take an antidepressant. It’s Kramer’s future of a heavily medicated population. But I doubt anyone would argue that we’ve become Kramer’s pumped-up society of the hyper-well.

The self, with its sharp elbows, remains. As does the body. Things like immune disorders, inflammation, and non-psychiatric drugs can cause depression; we know that the body impacts the mind. But biology is just one piece of distress, often a minor one.

And we live in a culture constantly calling for the William Blakes of the world to be “assessed”—which still means, most of the time, a DSM, a disorder, and a drug.

Hotz, Julia. (2024) The Connection Cure: The Prescriptive Power of Movement, Nature, Art, Service, and Belonging. Simon & Schuster.

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