What Is Normal?
There are many labels for variations of mental functioning, some clinical, some colloquial: Mental illness. Mental disorders. Being Crazy. Hysteria. Maladjustment. Being of unsound mind. Not right in the Head. Madness. Neurosis. Troubled. Insane. And there are also many clinical ways of describing constellations of symptoms, known generally as disorders: Depression. Anxiety. Bipolar. Mania. Obsessive Compulsive. Psychosis.
All of these terms carry a somewhat negative connotation and denote someone who is not “normal.” A few years ago, in Sonya Rene Taylor’s book, The Body is Not an Apology, I encountered the term “neurodivergent.” It implies a neurological system that functions in some way differently from the average person’s neurology. This may be the only label that feels neutral and authentic to me as a general term for the myriad of conditions that make up the family of characteristics cared for and treated by people in the field of mental health. However, the subtext in the title, “mental health,” often seems more to be one of mental un-health.
But how do we define what is normal? I ask this question of my clients often. It turns out, we can define the word in a number of different ways. Merriam-Webster for example defines normal as an adjective in several subtly different ways:
1a: conforming to a type, standard, or regular pattern: characterized by that which is considered usual, typical, or routine
b: according with, constituting, or not deviating from a norm, rule, procedure, or principle
2: occurring naturally
3a: approximating the statistical average or norm
b: generally free from physical or mental impairment or dysfunction: exhibiting or marked by healthy or sound functioning
c: not exhibiting defect or irregularity
d: within a range considered safe, healthy, or optimal
Looking at these ways of describing the meaning of normal, we see that mental health conditions or neurodivergence can be considered both normal and not normal. For example, normal in that they occur naturally. Given that the rates of depression have been steadily increasing over the last several decades and is now considered a major cause of disability globally, we can also say that depression is actually typical or routine, making the case that depression is actually quite normal. On the other hand, using depression again as an example, it may be viewed as constituting a mental dysfunction, or a deviation from healthy or sound functioning and therefore not normal. Depression can also be outside of the range of safe, healthy, or optimal.
So which is it?
Is depression normal or not normal?
And if we don’t know the answer, how do we know what our goal is in treatment? Are mental health professions helping people who are not normal become more normal? Or are they assisting people navigate through very normal troubles given the nature of society today? Are people getting better under the current model? In his most recent book, The Myth of Normal, Dr. Gabor Maté outlines his assertion that mental illness and problems like addiction are actually quite normal responses to the social, cultural and physical environment we all occupy in the modern world.
Despite now decades of treatment for depression using selective serotonin reuptake inhibitor (SSRI) medications, as well as a recent normalization of asking for mental health help and being open about the use of psychiatric medications, how many people can say they have been cured of their depression? At best, depression and other mental health conditions become well managed chronic illnesses and medications manage their symptoms. No one’s depression has been cured by SSRI medications, in fact rates of depression have skyrocketed since their introduction, especially in the wake of the Covid-19 pandemic.
In 2022, The Lancet published a study that demonstrated an increase in mental health disorders, using the epidemiologic metric known as Disability Adjusted Life Years (DALYs). This study found that between the years of 1990 and 2019, the global number of DALYs due to mental disorders increased from 80.8 million to 125.3 million, an increased from 3.1% to 4.9%. Of course, these numbers predate the Covid-19 pandemic and numbers reflecting post pandemic reality are not yet available as of this writing in 2023. However, according to a 2020 paper published by JAMA, rates of depression in the United States during the pandemic easily tripled. Have things improved over the last three years in this area of health? It hardly appears so. While recent data on the topic is lacking, it seems that we can look around us everywhere and see continued signs of this trend.
People seem to be getting worse, not better. Even now, with media awareness and a cultural shift normalizing conversations around mental health, people are suffering. To make matters worse, the healthcare system that was already fractured prior to the pandemic seems to be crumbling everywhere we look. Healthcare professionals are leaving their fields, and mental health services that were already overburdened continue to struggle. The Health Resources and Services Administration has estimated a shortage of psychiatric providers in the US reaching into the next decade. Based on recent census data, as many as a third of Americans already live in areas with inadequate mental health services.
To make matters more challenging, when people are able to find treatment, at least 30% of people with diagnosed depression experience treatment resistant depression that doesn’t respond favorably to the normal set of medications.
So what do we do?
One possibility is examining new and novel treatments and approaches for treating mental health conditions as well as treatment in non-traditional settings. Ketamine, a medication FDA approved for anesthesia since the 1970s is one of these novel treatments. It has been heralded by many in the psychiatric research community as the greatest advance in mental health treatment in the last 50 years. As a therapy it looks very different from conventional medical management, which typically involves daily medications taken at home by mouth, potentially for years or a lifetime. Many of these medications need to be carefully titrated over weeks to months and many patients need to try a variety of different medications before they find one or a combination that make them feel well, or for many, allow them to feel “normal.” Ketamine on the other hand, is often given as a series of injections in a clinic setting. It makes the recipient of the treatment feel mentally altered for a predictable amount of time, but once the acute effects dissipate, many notice a shift in mood withing 24-48 hours. After a typical introductory series of six sessions over the course of several weeks, many people experience a total reversal of their symptoms that may last for months. A booster injection or infusion at an often predictable interval of weeks to months is typically adequate to keep people from experiencing clinical depression and anxiety.
Is ketamine a cure for depression? This case could be made, there is compelling data on it’s efficacy in treatment resistant depression, but I hesitate to label it a cure. I believe it holds tremendous power for healing but it is only one part of the healing journey. My philosophy as a professional who administers ketamine for mental health purposes after using it as part of my anesthesia practice for years, is that it is a useful (and potentially lifesaving) tool. True healing is a journey that takes many years to establish, but it is not truly a destination. It is a process. The root meaning of the word heal is “to make whole.” And when a path to mental health is undertaken as a process and supported through a variety of interventions, the aforementioned question of normalcy actually becomes less important. It is not about being normal or not being normal, however we define that word. It is about our own personal wholeness. When viewed in this way, we can view the mental health field not as correcting or curing disorders, but instead supporting and assisting individuals to live their best lives, normal or not.
I believe in everyone’s capacity to heal. Some wounds leave scars that last a lifetime, but that does not mean our quality of life cannot be improved as we do our own personal healing work and move toward wholeness. So instead of trying to achieve some definition of normalcy, I want healing for my patients.
Global, regional, and national burden of 12 mental disorders in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burdern of Disease Study 2019
GDB 2019 Mental Disorders Collablorators
JAMA Netw Open 2020 Sep; 3(9): e2019686
Prevalence of Depression Symptoms in US Adults Before and During the COVID-19 Pandemic
Catherine K. Ettman, BA,1,2 Salma M. Abdalla, MD, MPH,1 Gregory H. Cohen, MPhil, MSW, PhD,1,3 Laura Sampson, PhD,1 Patrick M. Vivier, MD, PhD,2,4 and Sandro Galea, MD, DrPH1
The Prevalence and National Burden of Treatment-Resistant Depression and Major Depressive Disorder in the United States. Maryia Zhdanava 1 2, Dominic Pilon 1, Isabelle Ghelerter 1, Wing Chow 3, Kruti Joshi 3, Patrick Lefebvre 1, John J Sheehan 3 Journal of Clinical Psychiatry. 2016.