When I tell a patient that she has major depressive disorder, something subtle happens in the room. What I mean and what she hears may be two very different things.
I may mean that her symptoms meet an established set of criteria: depressed mood, loss of interest, changes in sleep or appetite, impaired concentration, and enough distress or dysfunction to cross a diagnostic threshold. She may hear something considerably stronger: The doctor has figured out what is wrong with me.
Those are not the same statement.
Most psychiatric diagnoses are syndromes: recognizable patterns of symptoms that tend to occur together. They are useful. They give clinicians a common language, help organize research, guide treatment decisions, and allow patients to put a name to experiences that may have frightened or confused them. But a syndrome is not necessarily a disease.
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That distinction is familiar elsewhere in medicine. Fever is real. Delirium is real. Edema is real. Each can be clinically important and require treatment. But identifying the pattern does not tell us what produced it. The same outward presentation can emerge from very different underlying processes. Much of psychiatry still operates at this descriptive level.
Two people can both meet criteria for major depressive disorder while having remarkably different illnesses. Their symptoms can differ, their courses can differ, the circumstances surrounding their depression can differ, and whatever biological and psychological processes produced those symptoms may differ as well. The diagnostic label tells us something important about how they are suffering. It tells us much less about why.
Schizophrenia presents an even more striking example. The diagnosis encompasses varying combinations of hallucinations, delusions, disorganization, cognitive impairment, and negative symptoms, with enormous differences in severity, course, functional outcome, and treatment response. Calling all of these presentations schizophrenia is clinically useful. It does not establish that every patient given the label has the same underlying disease.
This is one reason psychiatric diagnoses can sometimes seem strangely unstable. A person’s diagnosis may change as symptoms evolve, additional history becomes available, or the longitudinal course becomes clearer. That does not necessarily mean the first clinician was incompetent or the second one finally discovered the “real” disease. Sometimes the descriptive category that best fits a patient’s presentation simply changes as the presentation itself changes. Yet I don’t think we explain any of this particularly well to patients.
We commonly say, “You have depression,” “You have bipolar disorder,” or “You have generalized anxiety disorder.” Grammatically, these statements sound remarkably similar to “You have diabetes” or “You have strep throat.” The language suggests that medicine has identified a discrete entity inside the patient.
That language can subtly turn a description into an explanation. Once the label is in place, both doctor and patient may feel that the central question has been answered. But the diagnosis should instead open the next set of questions: Why this person? Why these symptoms? Why now?
We still need to understand the course of the illness, family history, temperament, development, medical conditions, substance use, trauma, relationships, sleep, environment, and the circumstances in which symptoms improve or worsen. The diagnosis organizes those questions. It does not answer them.
This distinction matters because stopping at the diagnosis can produce a false sense of completion. If a patient meets criteria for major depressive disorder, the work is not finished. The diagnosis tells us what pattern we are looking at. The clinical task is still to understand what is producing and sustaining that pattern in this particular person.
And that understanding can matter enormously. Two patients who satisfy the same diagnostic criteria may require very different approaches because their symptoms arise in different contexts, follow different courses, and respond to different interventions. The shared label gives us a place to begin. It should not persuade us that we already know where we will end.
What I would like patients to understand when I give them a psychiatric diagnosis is this: There is a recognizable pattern to what you are experiencing. Medicine has a name for that pattern. The name can help us decide what to investigate and what treatments might help. But the name is the beginning of our understanding, not the end of it.
Psychiatry does not need to be embarrassed by that uncertainty. Our patients are better served by an accurate description of what we know than by an appearance of certainty we have not earned.
A psychiatric diagnosis can be valuable without being the final answer. Patients deserve to know the difference.
Nebyou Belay is a practicing psychiatrist with twenty years of experience treating children, adolescents, and adults. He is affiliated with the Brown University Department of Psychiatry and practices at Rhode Island Hospital and Newport Hospital.
He writes about the practice of psychiatry itself: how diagnoses are made, how they’re communicated to patients and families, and how psychiatric language is understood (and often misunderstood) in the wider culture. His work touches on the science and the limits of psychiatric assessment, the boundaries of what medication and diagnosis can realistically offer, and the growing overlap between clinical language and everyday identity.
Across all of it, his aim is the same: to help patients, families, and the public engage with mental health more honestly, with less oversimplification and less noise. He is currently writing a book, The Myths and Misunderstandings of Psychiatry, and is a contributor to KevinMD. He shares updates on LinkedIn.
