EDITOR—In their editorial Middleton and Shaw set up a false dichotomy between mental illness, which in primary care should be treated with drugs and psychological therapy, and generalised distress, which needs to be treated with empathy, social support, and understanding.1 Only generalised distress, they assert, represents a failure to respond adaptively to social challenge. If only it were that simple.

The 1995 survey of the Office of Population Censuses and Surveys and numerous surveys in primary care have used the general health questionnaire and the clinical interview schedule to detect mental disorders as they are defined by both the International Classification of Disease and the Diagnostic and Statistical Manual of the American Psychiatric Association. 2 3 But all such patients require empathy, support, and understanding, and most common mental disorders are at least in part reactive to social circumstances. The doctor must first detect that the patient is emotionally distressed and then respond appropriately. Not all those satisfying research criteria for a mental disorder will either wish to have, or benefit from, a medical treatment, but many will benefit from social support.4 The statement that the best treatment for depression in primary care is antidepressants and drugs is true, provided that the depression is severe enough.5

EDITOR—In their editorial Middleton and Shaw navigate between the poles of a debate that has vexed primary care and psychiatry for the past 25 years.1 They cite Kessler et al as an extreme example of the modernist psychiatric stance that seeks to understand why general practitioners do not detect depression.2 In counterpoint are studies suggesting that non-identification does not really matter anyway.3

To paraphrase the conclusion of the editorial: a greater effort should be made to define the comparatively small number of cases identified as positive through the …