When the first surgeon general’s report on mental health was issued on December 13, the psychiatric community was generally ecstatic. At last, mental illnesses and mental health coverage were being given the national recognition that they so desperately needed.

Two days later, however, their emotional high was deflated by a piece that appeared in the New York Times that was critical of the surgeon general’s report. And it came from no one less than one of their own—a psychiatrist.

Sally L. Satel, M.D., is a Yale University–trained psychiatrist and is affiliated with a Washington think tank called the Ethics and Public Policy Center.

Here, in essence, is what she wrote: Now that the surgeon general has put his imprimatur on the idea that one-fifth of America is in need of mental health care, America now has a mandate for treating 50 million people, with an endorsement of insurance coverage for mental disorders equal to that for physical illnesses. Although the surgeon general suggests that such care could be managed so that cost increases would be small, the more likely result would be a severe strain on scant resources, with people with minor mental problems, such as low-grade depression, siphoning off resources from those who are more mentally ill. And there is no reason that all those with low-grade depression must be treated for it, she contends. " Many," she insists, " will get better with a support group, the advice of an objective friend, or just some time."

Not surprisingly, a number of Satel’s psychiatrist colleagues are less than enchanted with these views. In a letter he sent to the New York Times, for instance, APA President Allan Tasman, M.D., wrote: " In what universe lacking in care and empathy does an illness have to be severe before it should be treated? Like most other illnesses, mental illnesses, when undiagnosed and untreated, can move from the mild to the severe: from dysthmia to suicide. The personal and societal costs of such an approach are astronomical. . . . Unlike Dr. Sally L. Satel, I hope that the surgeon general’s report results in greater access to nondiscriminatory coverage and care and points tens of thousands of Americans to the treatment they need. . . ."

Along the same lines, in a letter published in the December 17 New York Times, Kay Redfield Jamison, M.D., a professor of psychiatry at Johns Hopkins University School of Medicine in Baltimore, wrote: " As someone who studies, treats, and suffers from a severe mental illness—manic depression—I commend the surgeon general for his excellent, thoughtful, and fair report on mental illness. . . . Dr. Satel dismisses the need to treat ‘mild’ mental illnesses. Would she suggest that doctors ignore ‘mild’ cases of diabetes, heart disease or cancer? I certainly hope not."

And in a similar vein, also in a letter published in the December 17 New York Times, Michael B. First, M.D., an associate professor of clinical psychiatry at Columbia University College of Physicians and Surgeons, said: " Dr. Sally L. Satel uses the same kind of stigmatization that the surgeon general’s report on mental illness is designed to reduce; namely, that some diagnosable mental disorders can be overcome by sheer will and aren’t ‘real’ diseases. . . ."

In contrast, Marc Graff, M.D., a psychiatrist in Northridge, Calif., praises Satel for her many good articles that have appeared in publications as diverse as the New Republic, Wall Street Journal, and Women’s Quarterly. However, he told Psychiatric News that his concern about her December 15 piece in the New York Times is that instead of saying how wonderful the surgeon general’s report is, she says that we are now going to have people trivializing the mental health system. In other words, the " worried well" are going to clog up the system. And on the basis of his professional experience he simply doesn’t think that is going to happen, since people with a mental health problem usually first tap friends, family, and primary care providers before they finally go see a psychiatrist.

Barry Herman, M.D., a child and adolescent psychiatrist from Austin, Tex., who is now practicing in Amarillo, also commends Satel on her former articles, but not on her December 15 piece. " The surgeon general’s report was such a historic public health document," he said in an interview, " and it was really an opportunity to create a crack in the barrier that has existed so long to access, choice, and improved quality of care. [Satel] kind of threw a bucket of water on that. . . ."

Harold Eist, M.D., a former APA president, takes a similar stance. Satel, he said, writes " provocative pieces [that] one might view as conservative, very conservative, and sometimes people with a conservative point of view have something to offer. But on this one, Sally missed the boat. . . . She says, Hey, now that so many people have been identified as having mental problems, how are we going to afford it? Well, she forgets that our most important resources are human resources, and that we will not be able to function effectively as a country if we do not care for our human resources."

When asked what she thought of fellow psychiatrists’ criticisms of her piece, Satel told Psychiatric News, " I was struck by how they seemed to think that I don’t believe that people other than the most severely ill should get any treatment at all. That’s not what I’m saying. My point was that not everyone with the less-severe illnesses necessarily needs psychiatric help. . . . Many psychiatrists seem to think that as long as people meet the DSM-IV criteria, they need to see a psychiatrist. But I think that is up to the person." —J.A.T.