No More Normal: Mental Health in an Age of Over-Diagnosis

by Alastair Santhouse

At what point does a low mood tip over into depression? When does a distressing experience qualify as trauma? When does a cluster of symptoms indicate an underlying condition? As the conversation around mental health has moved from the consulting room to the public arena, so the concept of normal is shifting. Today, we are seeing an unprecedented rise in diagnosable conditions, in waiting lists, in diagnoses, and in medication.

Yet, are we really less psychologically healthy than previous generations? In this brave, engrossing and vitally important new book, consultant neuropsychiatrist Dr Alastair Santhouse argues that the consequences of the new climate of diagnosis are immense. Drawing on his decades of clinical experience, Dr Santhouse explores our current malaise and proposes a solution - that we pull back from this diagnostic expansion, focus on the effective treatment of a core group of severe mental health problems, and de-medicalise a vast range of other normal human experiences.

Genres: Nonfiction, Psychology, Science

287 pages, Kindle Edition

Published April 10, 2025

Reviews

[Lauren]

I only gave this 4 stars instead of 5 because I'm still mulling it over. This book gave me a lot to think about, both personally and professionally, and I would like to reread it again in maybe a year (it's a refreshingly quick read). I have dog-eared several pages already for research-related reasons, so I'll be revisiting those sooner than later.

This is the most "both sides" approach to psychiatry that I have read, especially coming from a practicing neuropsychiatrist. While the author is clearly against the "anti-psychiatry" perspective, and in my opinion maybe misinterpreting that perspective in some ways, his attunement to human experience and human suffering means that he inherently takes seriously some of its basic arguments. He doesn't mention Mad Studies or Crip Theory, but I get the sense that he would genuinely listen to these perspectives, and genuinely give them consideration. At the same time, he does have an essentially unproblematic optimism for the potential of large computational models. And yet he immediately couches this in terms of being a background for better understanding the individual.

All that deeper stuff aside, this book is just INTERESTING. There are stories in here that remind me of what drew me to Oliver Sacks' writing when I was younger, and there are lots of accessible summaries of recent research findings that will make your jaw drop. The overall point is a really important one, too: we, as a society, can do this better -- "this" being the treatment of mental illness. I'll type up one quote here, from page 101:

"In our time, in our culture, life is getting simultaneously better and worse. We have achieved a level of wealth and longevity that previous generations could only have dreamed about, and yet we have never been so unhappy. Depression is a diagnosis that has become emblematic of the early twenty-first century. Not a fashionable diagnosis, but a ubiquitous one.

The uneven rates of depression worldwide suggest we are picking up on something beyond a biological illness. Life is beautiful and fragile, and all too brief. It is painful to think how many years are being lost to depression and unhappiness. Psychiatry holds only some of the answers. The rest needs to happen in a different way, assuming it matters enough to us. We need to be thinking about what in our culture is generation so much sadness. Framing this as depression is what is leading to the sharp rise int eh diagnosis of depression and antidepressant prescription, and misses the point entirely."

[Sadhbh O'Sullivan]

2.5 rounded up. An interesting premise that prompted me to read this for work, but the actual focus was quickly lost. Interesting in parts (the risk assessment chapter stands out) I found it to be woolly and meandering.

[Saara]

Warmly recommended. Compassionate, empathetic and nuanced approach towards difficult and complex themes in challenging times when nuanced and good-faith discussions seem to be less prevalent than they should be, in my opinion.

[Andrew]

This book is a great addition to the literature questioning the current fashion for diagnosis and medicalisation as the preferred way of explaining and easing the psychological burdens of life. It comes from the formal psychiatric perspective and as a first read about the somewhat shaky scientific foundations of that medical speciality it opens the door a chink.

Each chapter is a balanced read and well-referenced, and the author wrestles with difficult subjects. He expresses some of the deep problems with overdiagnosis very well, principally the risk that falling thresholds for diagnosis are increasing the number of patients at a rate far faster than services are being developed. Those with the most uncontroversially pathological mental illnesses (schizophrenia, severe depression, severe childhood autism, childhood ADHD, bipolar disorder) are competing for mental healthcare resources with those with ‘disease’ that is unarguably mild by comparison. He dances through the controversies, and writes with evident compassion for anyone whose mental life and health creates a challenge.

What was a surprise, and a disappointment, to me was how inadequately he dealt with the main recurring theme, that of how to define normal, given that definitions of supposed ‘abnormal’ are currently running amok. Given the word is in the title of the book I expected at least an attempt at a defence… could it be that in fact it is indefensible?

The author very much writes as a psychiatrist, and I accept there is an understandable degree of indoctrination in anyone fully socialised into a profession. The final chapters see him glimpsing a world where things are thought about differently, where psychiatric disorders are conceptualised more empirically and rationally. The analysis of bereavement and the controversy around diagnosing depression in that context is all too brief, and fails to bottom out the issue. It is weird to me that an identical experience can in one context be called a ‘depressive illness’, and in another ‘normal grief’. Surely the predictable onset of depression following loss is the basis for understanding it in any context; surely the ‘normal’ context is a clue to the pathology, the psychic pathophysiology? The latter section left me wanting more, and with a feeling that the author retreated before asking too many fundamental questions of his own profession.

[Ellen]

A very interesting read- I have not read much about psychiatry before but found this all fascinating. The author is obviously a doctor who cares deeply about this patients and presents a thoughtful and compassionate view of various problems engaging modern psychiatry. As someone new to the topics here I found the writing engaging and accessible. He discusses the increase of mental illness diagnoses in current times, the rise in individuals seeking diagnoses of ADHD and anxiety and the rise of the TikTok tics that came about in the COVID pandemic. Where does normal human experience and normal struggle with the challenges of human experience end and mental illness begin? He discussed some of the challenges facing professionals in coming to a helpful diagnosis (helpful being the key word there!). He also discusses the risk-assessment focus of modem time- and resource-constrained practice and how potentially problematic this is. He provides lots of interesting case studies from his own practice to back up his arguments. He goes on to finish by looking at potential future direction including a hope that the plethora of new disease diagnoses now available will be unified and cut back in the future- which was an interesting perspective, and touches on the use of AI (he is sceptical) and the use of computer modelling (he can see a potential for this). A very interesting read if the mind and psychology, or even just the challenges of modern mental health interest you at all! I think I will want to re-read this book to really think through some of the topics a bit more.

[Sami Quadri]

Interesting book that sounds the alarm on how we’re turning ordinary life struggles into medical diagnoses. The result, according to the author, is that people with serious mental illness are being sidelined as waiting lists grow. He blends sharp stats with real-life stories, and doesn’t shy away from critiquing the rise of self-diagnosis culture and the role of pharma in expanding what counts as illness.

It’s punchy, relatable and makes you think twice about how casually we throw around labels like ADHD (I do this myself a lot!). That said, he leans a bit too heavily on blaming Big Pharma, and his solution (tightening diagnostic criteria) feels a bit oversimplified imho

Still, it’s a provocative, worthwhile read that challenges the idea that every low mood or bit of anxiety needs a medical label. Worth a few hours of your time.

[diaLOG]

作者显然是一个有多年临床经验的老医生，在写作时也采取了一种非常圆滑的观点表达方式。这对于这本书而言是好事也不算好事。

他很熟悉这个体系以及体系的演变，也有很多现代医生不会有的在其他国家问诊的经验。例如，他在第五章schizophrenia里提到他去苏联的经历，在那里，人们以“sluggish schizophrenia”为借口把政治对立的人送进精神病院，让他意识到精神问题诊断可能存在的政治性意义并对此警惕。又例如他在第七章traumatized里指出，PTSD的说法其实从1970年后（越南战争）才广为流传，WW1和WW2的老兵并没有越战士兵那么符合PTSD诊断标准（avoidance of reminders of the event），等等。

但一定程度上，这也导致有些章节很无聊，例如第十章Sex, Sexuality, Love and Gender。作者知道自己对于这个话题不熟悉，对于所有性取向和性别认同的患者表示极度尊重，没有任何“政治不正确”的言论，所以反而看上去很中庸，也没有特别能让我感觉戳中的点，看完就忘。此外，第八章The Rise (and Rise) of Neurodevelopmental Disorders虽然是我个人最感兴趣的一个话题，但依然让人看完就忘。毕竟他的主修方向和Neurodiversity基本没什么关联（他最早接受的是临床内科医生的训练，后来才转入精神病学，所以他特别擅长处理那些同时涉及身体疾病和心理健康的问题），他没有太多类似的一手资料；在这个章节的写作里和Allen Frances的Saving Normal以及Robert Chapman的Empire of Normality表达了很多重复的类似观点。

总之它更像是一本面向大众的科普或自序型的Self-help / General non-fiction，而不是能够提供严密生物学、神经科学证据的Hard science。我可能很快会忘掉这本书吧。

[Lily F]

Interesting, and clearly well informed. But I feel like a lot of the chapters lacked depth or an overall objective in what they were trying to achieve. Do think this is a good introduction into the world of mental health diagnosis, and particularly relevant within the current climate of psychiatry and mental illness in general. However I would like to see a more specific discussion about this, as many of the points raised appeared very broadly.

Though I can appreciate why this was the case, and that the tone of the book to be accessible and informative even for those not familiar with reading academic literature.

[Pritti Doidy]

This is a very interesting and thought provoking read. The author will inevitably cause some people to feel attacked and equally inevitably others to feel vindicated. Most will read this through their own political-cultural lens and miss the point entirely, which is to raise valid questions about the nature and necessity of the staggering recent increase in mental diagnoses - and not to patronise the reader by determining their views as right or wrong. A wonderful book, very well written and an important debate to have.

[Jane]

Well-written discussion of current psychiatric diagnoses. Their possible overuse and possible causes. Also, some interesting history of diagnoses. I felt Santhouse was supportive of his patients and his profession and spoke throughout with an adult voice. Rather than the 'isnt psychiatry a tragic but entertaining romp' tone of voice that seems obligatory in most popular psychiatry discussions. Also, he didn't cram in medical urban myths - which also seem compulsory in popular psych books.

[Jessica]

The colloquial tone and style is one I don't often find easy to interpret. I found the content of the book was slightly too general or subjective for me to quite follow. I don't think the opinions or reflections talked through were quite clear to me or deeply explained the way I might hope. Not that they necessarility needed to be, but I found the book un enjoyable.

[ettie]

i really didn't enjoy this book. it felt really one sided, and i felt as if he was constantly ignoring and/or invalidating those with mental illnesses, arguing that those who suffer with milder depression take away help from those suffering with severe depression. genuinely not sure what the author was trying to get out of writing this book.

[Ashley]

Santhouse writes very fluently and his tone reflects his personal views clearly. No More Normal is an informative read, demonstrating his considerable experience and wisdom, that holds one’s attention well.

[Mrs Belinda]

A timely and thought-provoking read. The book shines a helpful, expert and compassionate light on a wide variety of mental health issues, and provides valuable insight. Beautifully written so as to be accessible enough to the ordinary reader.

[Daisy]

This is a book that needs to be read. The message is crucial in today’s world and eloquently put. Highly recommend

[Jo]

Really enjoyed listening to this. And to understand the other side of this

[Helena Taylor]

Really enjoyed this book and could agree with alot of what the author talked about , and highlighted similar worries I have for our society. A good read and very personable tone

[Sam Santhouse]

Brilliant