Although depression can be associated with feelings of sadness or emotional breakdown, it can manifest in other ways.
An individual can feel emotionally exhausted all the time, lose interest in hobbies, or even feel numb, leaving them to go unperturbed.
Because the symptoms can be unnoticeable, people can carry these feelings for months or even years.
In this post, the focus will be on signs that often go overlooked because they do not match the criteria people argue to be true for a diagnosis of Major Depressive Disorder.
Why Depression Is So Often Missed, Even by the Person Living It
One of the most important reasons that Major Depressive Disorder remains unrecognized is due to the heterogeneity of its symptomatology.
Means that the presentation of the disorder is varied across individuals.
The DSM-5 has criteria that specify a cluster of symptoms, not a single defining symptom.
This means that it is entirely possible for someone to experience the disorder while never feeling “classically sad.”
Many symptoms of MDD also overlap with everyday stress, feeling burnt out, or dissatisfaction with life in general.
It is easy to explain away depressive symptoms by saying “I’m just tired,” or “I’ve just been busy” or “this is just how life is right now”.
By the time the dots are connected, depressive symptoms are often already causing a major impairment in daily functioning.
The Impact of Stigma
The shame associated with mental health leads to a lack of self-discernment in regards to depression.
This is especially seen in male individuals, elderly folk, and individuals from cultures with minimal discourse on mental health.
Realistically, they overshadow their internal struggles with the thought of “being depressed”, rationalize their emotional state, and hope to simply work through what they are going through.
To the frustration of many, their situation improves, but frequently, it does not.
The Nuanced Indicators of Depression
The most insidious and damning indications of depression are those which are most likely to be justified, and which, in the aggregate, may sum to depression in its most clinical of definitions.
1. Chronic Exhaustion, from which No Amount of Sleep Can Provide Relief
It is perhaps to be expected to describe an ongoing exhaustion in terms of work obligations, sleep deprivation, or simply getting old.
In depression, however, this state of fatigue is biologically driven.
It is the result of clinical alterations of the HPA (hypothalamus-pituitary-adrenal) axis, and changes in the balance of the brain chemicals responsible for modulation of emotion, e.g., serotonin and dopamine.
This may result in a state of sleep in which you have not, and will not, experience what is commonly understood as “rested”.
- Simple, everyday tasks drain your cognitive and physical resources.
- It takes much longer than before to feel rested.
- Fatigue triggers cognitive tiredness and a lack of focus.
2. Having a Lack of Interest and Pleasure in Activities
Anhedonia is a clinical term for the absence of pleasure or enjoyment in activities that are typically pleasurable or enjoyable.
A lack of interest and pleasure in activities like:
- Socializing
- Eating
- Even intimacy
Even though you appreciate the activity, you are just going through the motions.
You almost have to go to the social event as a chore rather than going to have fun.
Interest in food, music, hobbies, etc., has just slowly gone away and faded.
- You find the activity enjoyable but you are simply going through the motions.
- You feel obligated to attend social gatherings rather than attending to enjoy yourself.
- Your interest in food, music, or hobbies has quietly faded. Your lack of enthusiasm is evident.
3. Increased Irritability and Increased Sensitivity to Frustration
Someone who is experiencing depression expresses it through sadness rather than irritability.
Low emotional control, increased sensitivity to frustration, and anger outbursts are all diagnostic signs of depression.
This is referred to as “irritable depression” and is often found in older children and adult men.
- When faced with a trivial inconvenience, your frustration is evident.
- You tend to feel anxious for no apparent reason.
- You snap at people even when you love and care about them.
- Anger usually results in guilt or numbness, followed by a surge of other emotions.
4. Psychomotor Changes – Moving and Thinking More Slowly
Motor function is influenced by a person’s emotional state.
Psychomotor retardation is the medical phrase that describes an observable decline in the velocity of a person’s movements, speech, and the speed at which they think.
Contrastingly, some individuals manifest signs of psychomotor agitation.
Psychomotor agitation is a state of inner restlessness that makes remaining still a substantial challenge.
Both conditions are classified as psychiatric disorders in the DSM-5 and are commonly attributed to issues such as stress, aging, or mere distraction.
- You feel like your mind is entangled in an enormous fog.
- You feel more like a tortoise than a hare when you move than normal.
- Making decisions is such a difficult task.
- You feel a restless “trapped” energy that you can’t explain.
5. Alterations in Sleep Patterns
Sleep is one of the depressive symptoms that people usually downplay, even when they are most common.
The changes in sleep patterns in people with depression go beyond the occasional insomnia.
Depression is associated with alterations in the regulation of the circadian rhythm as well as changes in the patterns of REM sleep.
This may present as early-morning awakenings, hypersomnia, or fragmented sleep that leaves you feeling worse upon waking.
- You wake up early and have difficulty falling back asleep.
- Your sleep patterns are concerning, as you are oversleeping in the first place.
- You are sleeping the recommended hours per week but are still waking unrefreshed.
- You are experiencing vivid or disturbing dreams.
6. Appetite and Weight
Appetite changes in either direction are behavioral components and symptoms of depression.
Some experience emotional eating or cravings as self-soothing, whereas others report a complete loss of appetite.
Reward pathways and regulatory centers of hunger are disrupted in these cases.
- Your eating patterns have changed.
- You lost or gained weight when you did not want to change your habits.
- You are eating for comfort more often.
7. Difficulty with Concentrative and Executive Functions
The effects of depression on cognitive functioning include parts of the thinking process like attention, working memory, and executive function.
Some people might think of these things as stress or distraction, but for a lot of people, these are the symptoms of depression as the main problems.
- You have to understand the same point yet again.
- Your ability to focus is gone.
- You experience a level of forgetfulness that you have never known.
- You started working on some tasks, and it looks like you are having a hard time finishing them.
These symptoms are not your personality flaws.
How Depression Can Look Different Depending on Who You Are
While we may think of depression as a symptom of specific clinical markers, it is presented in different forms.
These forms vary based on age, sex, culture, and situational context. The lack of knowledge of this is often the reason for many misdiagnoses or failures to diagnose.
Depression in Men
Although men are diagnosed with Major Depressive Disorder (MDD) at a much lower rate, men are known to attempt suicide at much higher rates.
Partially, this is due to men being more likely to show behavioral than emotional manifestations of depression.
Depression in Older Adults
Misconceptions surrounding geriatric depression often conflate the condition with the grieving process, cognitive decline, or even normal aging.
Depression in People of Color and Culturally Diverse Communities
Depression is continuously underdiagnosed in the Black, Latino, and most culturally diverse communities.
This results from a combination of factors, including a cultural value of resilience, public discourse, historical distrust of the health care system, and clinician bias.
Culturally sensitive care is not optional; it is necessary.
High-Functioning Depression
This condition is also known as Persistent Depressive Disorder and, in its longer-term form, is known as Dysthymia.
It describes people who seem to be fine and have high levels of emotional pain. They are always at work and manage their obligations. While they are at home, they are empty.
When “Pushing Through” Stops Working
Everyone facing a tough phase tends to have their own methods for getting through it: staying busy, maintaining strong routines, or powering through with willpower.
For now, these methods seem to work. In the case of depression, however, it gradually gets worse, especially when left untreated.
The alterations in neurobiology due to chronic depression, including ongoing dysregulation of cortisol and changes in volume of the hippocampus, and so on, are not speculation.
They have a progressively negative impact on the structure and function of the brain.
This isn’t meant to frighten. It is reframing our priorities.
You seeking help for your depression is not a sign of weakness. It is not reserved for when people are in an acute crisis.
It is a reasonable response to an equally reasonable problem. Addressing a depression issue early on is associated with better outcomes.
- Most people would agree you have been “pushing through” for months, not days.
- Multiple coping strategies are providing no relief.
- You’ve started to notice your relationships, your performance at work, or your physical health are suffering.
- You’ve started thinking, even if it isn’t openly so, that perhaps there is more to it.
If you are, or someone you know is, having thoughts of self-harm or suicide then you can call or text 988 for help at the 988 Suicide & Crisis Lifeline.
What Getting Help Actually Looks Like
One of the biggest barriers to seeking help is not knowing what to expect – and fearing that care means something drastic, intrusive, or life-disruptive.
The truth is, though, getting evaluated for depression is usually just a simple conversation with a qualified provider.
What a Clinical Evaluation Involves
Most comprehensive depression screenings include:
- A structured clinical interview
- An assessment tool (such as the PHQ-9
- Patient Health Questionnaire-9)
- A review of the individual’s medical and psychiatric history
- A discussion of other contributory factors (sleep, lifestyle, meds, etc.).
Treatment Approaches
In depression, evidence-based treatment can be one or a combination of the following, depending on the severity of the symptoms and what the individual needs the most.
In general, Antidepressant medications SSRIs or SNRIs) are a type of pharmacotherapy and can be quite effective for moderate to severe depression.
In the management of depressive symptoms, the importance of sleep, exercise, diet, and stress management cannot be overlooked in depression.
These are all very useful measures.
When working with a provider who integrates both mental and physical health care, your whole health approach improves, leading to better results.
Telehealth Makes It More Accessible Than Ever
No need to sit around for a face-to-face visit. No need to spend a workday looking for a parking spot and waiting to see a clinician.
Mental health care via telehealth has become even more convenient, with many appointments available in a matter of days.
Avoid waiting for issues to snowball.
Reach Out
At Wade’s Care First, Charles Wade, FNP-BC, offers mental health services, including evaluation and treatment of depression and other mental health conditions.
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