A relationship ends, and she cannot sleep.
A parent dies, and his appetite disappears.
She loses her job and spends weeks feeling anxious and struggling to concentrate.
Some of these patients will arrive in our offices. They will tell you they are sad, anxious, exhausted, and unable to cope. They may even complete a PHQ-0 or a GAD-7 that shows they are depressed and anxious.
However, as a psychiatrist, I often pause and ask myself: is this person mentally ill or are they suffering?
Major depression, anxiety disorders, post-traumatic stress disorder, bipolar disorder, psychotic illnesses, and other psychiatric conditions cause enormous suffering. Diagnosis can give patients language for experiences they have struggled to understand. Diagnosis can also allow treatment to be focused. And I diagnose and treat psychiatric illness every day. I have seen medication, psychotherapy, hospitalization, and other interventions change and save lives.
At the same time, we, as psychiatrists, must be mindful about what we ask diagnosis to do.
Psychiatry occupies an unusual place in medicine because many of the symptoms we assess also belong to ordinary human experience. Sadness is not exclusive to depression. Worry does not necessarily indicate an anxiety disorder. Insomnia can follow heartbreak. Poor concentration can accompany overwhelming stress. Appetite can disappear during grief. A person whose life has suddenly become frightening or unstable may feel frightened and unstable.
The context says everything.
But I worry that healthcare increasingly relies on tools like questionnaires or brief telehealth assessments that make context difficult to capture. The tool should not be the entire assessment.
Consider a patient whose spouse recently died. They are sleeping poorly, crying frequently, eating less, struggling to concentrate, and experiencing anhedonia. Those symptoms overlap with major depression. But what do we label that experience?
There is no simple answer, and there should not be one. Grief does not protect someone from developing major depression, and bereavement can coexist with psychiatric illness. Conversely, the presence of depressive symptoms following a devastating loss does not automatically mean that grief has become a depressive disorder.
The distinction between the two requires clinical judgement. And we should not be diagnosing a patient without this careful judgment. Diagnosis does more than determine a billing code or treatment pathway — it can change what our patients understand about what is happening to them.
“I am devastated because someone I love died” is a different narrative from, “I have a psychiatric disorder.” While those statements can coexist, they are not interchangeable.
Medicine has trained us to identify pathology. We look for symptoms, name them, and decide what to do next. That often serves us well. But I wonder whether, at times, psychiatrists move too quickly from “This hurts” to “This needs to be fixed.”
Sometimes what a patient needs most from a clinician is not a diagnosis or medication but someone willing to remain curious long enough to understand what happened. When every painful human experience is interpreted primarily through a medical lens, we risk communicating that emotional discomfort itself is evidence that something has gone wrong.
At the same time, context does not immunize someone against psychiatric illness. A recognizable precipitant does not make severe symptoms benign. The person whose marriage ended can develop major depression. The bereaved parent can become suicidal. The overwhelmed new mother can have a serious mood disorder. Saying “Of course you’re sad” is not an adequate psychiatric assessment.
This is where clinical judgment comes in. We need to not only ask, what symptoms are present? But also: what happened? How long has this been happening? How much has functioning changed? Is the response evolving? Is the patient at risk? What was this person like before? And has something qualitatively shifted from understandable distress into psychiatric illness?
Those questions take longer than completing a screening tool; but they keep the human being behind the symptoms front and center.
Put simply, we should be able to hold two ideas simultaneously: psychiatric illness is real and deserves treatment, and not everything that hurts is an illness.
There is a space between pathologizing suffering and dismissing it, and this is the space where much of psychiatry actually happens. Sometimes the work is to diagnose, other times it is to treat, and many times it is to sit with someone long enough to understand why they hurt before deciding what to call it. Even with more tools emerging, psychiatrists must always keep this central to our practice.
