Some People With Depression Don't Know They Have Depression

You'd be forgiven for thinking that depression is merely low mood. It's much more intricate and multi-layered than that.

You'd be forgiven for thinking that depression is merely low mood. It's much more intricate and multi-layered than that.

This blog was inspired by a recent medico-legal assessment that I undertook. There was a man who I was assessed on behalf of the Criminal Court who had been charged with an assault and was facing a potential prison sentence. He'd had a difficult childhood, with an alcoholic father who used his fists to do the talking and was always in a bad mood (perhaps 'dysthymia', see later). This client had recently had a series of difficult life events; two relatives had died, his partner had left him and he was made redundant - all within the space of a year. You have to feel for the guy, no matter what he had done. He didn't recognise his own low mood and had a series of subtler symptoms of depression, which I helped highlight for him. He knew something was wrong but suffered in silence for years before therapy gradually pulled him out of the darkness.

Depression is complicated. For a start, not all people with low mood have depression. For example, low mood could be a temporary and natural, non-pathological (psych-jargon for 'normal') reaction to particularly troubling life events or bereavement. Or perhaps, it could be a presentation of another psychiatric illness (for example Bipolar Affective Disorder or schizophrenia). It could even be a short-lived result of partying too hard and over-indulging over the weekend (wink, wink).

Clinical depression (as opposed to layman's depression) is twice as common in women than in men and around 1 in 6 people suffer from it significantly throughout their lives.

There are obvious risk factors and associations; these include genetic predispositions, a difficult childhood (abuse, criticism, lack of close relationships), life events (death of a close family member, or divorce) or listening to Coldplay. However, there are less obvious risk factors and causes, such as physical illness (e.g. an underactive thyroid gland).

Also, somebody can be chronically a little bit low but not enough to cross the (admittedly arbitrary) threshold for depression. In psych-jargon, this is called 'dysthymia'; in real life it is called grumpiness.

So anyway, it's getting late - what about the aforementioned people who don't know they have depression...?

As well as low mood, the core features of depression are anergia (psych-jargon for lack of energy) and anhedonia (a lack of pleasure in any activities). There are also the sneakier, less conspicuous symptoms like irritability, feelings of worthlessness and uselessness, poor concentration and memory, a lack of appetite, weight loss, poor sleep and even constipation and aches and pains.

The trouble is, most (if not all) of those symptoms are not 'pathognomonic' (i.e. don't definitively prove that depression is present). Plus, most could potentially be caused by other illnesses or even normal life stresses. Diagnosing depression accurately isn't straight forward. That's why you need people with degrees, beards and pipes to step in. Not really, though I do think clinical experience, open-mindedness and empathy are key. In other words, by seeing hundreds of definitely, maybe, probably and probably not cases of depression, a clinician (if they have been concentrating) can pick up the truly valid cases, including the more subtle presentations. There are a myriad of ratings scales that exist to diagnose depression. In fact, there are rating scales for almost everything in psychiatry; even to measure aggression objectively! Personally, I think that clinical experience always trumps these scales, as the latter can be subjective, used variably and misinterpreted.

Because low mood is not always detectable and obvious, some people may have depression and not even realise it. They may not recognise it or wish to accept it because of the associated stigma. Some people may be too proud to admit they have a problem. In theory, I can understand why this is but unfortunately this might prevent them from seeking treatment. This is such a shame because treatment could potentially improve their outcome / prognosis / life.

I can think of specific examples of undetected depression that I have personally encountered in my many different psychiatric arenas of work. Strikingly, 'depression-in-disguise' seems to be more prevalent in certain cultures. For example, some African and Indian backgrounds often struggle to accept depression as a concept. If this is programmed into cultural DNA, what chance does any one individual from this kind of background have of speaking up if they are feeling low? Sufferers of depression from these backgrounds therefore often present in an unusual manner; for example physical symptoms that have no discernable medical basis. They even occasionally prevent with a sudden loss of bodily functions; like sudden temporarily blindness or paralysis of a limb. It might sound absurd but I've seen it. In these poor souls, a plethora of medical investigations have often proved fruitless. However, after eliminating a series of red herrings, some talking therapy or anti-depressants can alleviate the underlying problem.

Obviously, stigma of mental illness anywhere is a thorn in the side of progress and needs to be tackled. But I would argue that it is doubly important in this group, as it must be extra-hard for people to 'come out' if they originate from a background that is prejudiced against mental illness... or should I say 'extra'-prejudiced against mental illness.

From my experience, some elderly people who develop depression also can present unusually. Sudden acute loss of memory is common. Again, this is a red herring; treatment for dementia can prove frustratingly useless whereas treatment for depression can be a lifesaver.

So the take home message is... don't listen to Coldplay.

Not really, the take home message is that if any of the above seems to describe you or somebody close to you, you need to get some help. As a first port of call you should see your General Practitioner. They might be able to divert you to another helpful service such as counselling or psychotherapy. Tablets can help but aren't always the answer. They tend to be reserved for people with a more severe type of depression or for when talking therapy has failed.

Ignoring these (admittedly subtle and confusing) signs could prevent you from dealing with a very common and treatable disorder. You owe it to yourself to try to be happy.

If you think you have depression, here are some good places to start researching:

Have any of you or people you know had experiences of depression, or even depression-in-disguise? Please share your story.

The more we all speak out, the more we encourage others to do the same.

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