Depression doesn’t always “present” as it should. Prolonged sadness, lack of hope, or loss of interest in previously enjoyed activities are the most commonly mentioned symptoms on mental health websites and in antidepressant ads, and they can certainly be the most affecting. But sometimes the disorder is subtler, and harder to identify, since it can make itself known in stranger ways than we’d like. Below are some of the less obvious, but nonetheless important, symptoms of depression – those you should be aware of (and which you should make your psychologist/psychiatrist aware of, if you’re seeing one). Knowing that depression can play out in counterintuitive ways is important, since knowing that you’re depressed is the first step in seeking help for it.
Depression can poke through in unexpected ways, both physical and behavioral – it’s kind of like depression is finding a way out, if it isn’t being acknowledged otherwise. “Some people, particularly men, are more likely to externalize their depression,” says psychologist and author of When Depression Hurts Your Relationship, Shannon Kolakowski, PsyD. “Depression symptoms come out through excessively drinking alcohol, seeking out an affair outside of the relationship, becoming aggressive, or withdrawing from those you love. Similarly, physical symptoms like backaches or low sexual desire are less recognized as depression because they’re externalized.” Extreme fatigue – both mental and physical – is a common symptom (of course it can be indicative of other things, so it’s important to get checked out), as are changes in eating habits (not eating, or conversely, overeating) or sleep patterns.
This is an extension of the one above, but worth highlighting, since it’s more specific, and may actually indicate a more severe form of depression. Sometimes the disorder can emerge as irritability or anger – when some part of you is at a loss internally or feeling helpless or hopeless, it’s easy to lash out. “Experiencing irritability, hostility, anger, and being sensitive to rejection are all common symptoms when depressed,” says Kolakowski. “Less well known is the fact that not only is irritability a sign of depression, but that it often signals a more severe level of depression. Hostility and irritability are also linked to a higher likelihood of having other mental illness, like anxiety. Other emotions such as sadness, shame, or helplessness often underlie the irritability, but irritability is what shows up on the surface.” If you’re noticing that you’re very short-tempered, or yelling at your spouse or kids a lot, or otherwise lashing out, take some time to think about what might emotion/s might be driving that behavior.
Perfectionism and depression have been long connected to each other, and research studies have underlined the association for years. “Having all-or-nothing, rigid, and exceptionally high or unrealistic expectations are all symptoms of perfectionism, and can all contribute to depression,” says Kolakowski. “Perfectionism in depression tends to belie the idea that others will only love and accept someone if they’re perfect.” Self-esteem is what seems to mediate the link between perfectionism and depression, since perfectionists often think that they must be “perfect” to be acceptable, both to peers and themselves. “To perfectionists, to make a mistake is a sign of a personal defect or flaw, rather than the fact that it’s human to make mistakes, and that we all make mistakes. To counter the self-blame, fear of failure, and shame that comes with this, practicing self-acceptance and compassion are essential.” That may be very hard to learn to do on your own, so might need the help of a capable psychologist.
Inability to Concentrate
Everyone has problems concentrating from time to time, especially if something specific is on your mind. But pronounced concentration issues – so much that they affect your work or relationships – can also be a sign of underlying depression. “Concentration difficulties are a common symptom of depression, yet one that people may not associate with depression (think ADHD),” says psychologist Jon Rottenberg, PhD, author of The Depths: The Evolutionary Origins of the Depression Epidemic. “Many of the symptoms of depression are private experiences like sadness or feeling worthless, problems that people can conceal from others. What’s striking about concentration difficulties is that they directly impair functioning – these difficulties make it harder to work or go to school. Concentration problems can make people miss assignments or deadlines.” He adds that it’s often these issues that prompt a person to get help in the end, since they’re less easy to hide from one’s coworkers, boss, or family. Concentration may be compromised because of another serious symptom of depression – rumination – in which a person turns certain topics over and over again in one’s head (past regrets, future worries), which can be time-consuming, futile, and depressogenic itself. And it can severely compromise one’s ability to concentrate on the present.
Extreme Guilt (about Ridiculous Stuff)
Guilt is obviously a natural sensation at times, but sometimes a deep feeling of guilt about many or most areas in your life can signal depression. Rottenberg calls it “pathological guilt,” and says, “what’s different for the depressed person is that the guilt can become all-consuming. He or she scans the past and sees only a series of failings. Sometimes the guilty thinking can become quite fanciful. The depressed person can feel guilty for being born, guilty for having had depression, and be unable to think of any major life role (friend, son or daughter, parent) without being consumed by feelings of regret.”
You Don’t See ‘Smiley Faces’
Being a “Debbie Downer” is sort of a funny joke, but there’s a much more macabre side to it: When you immediately pick out every negative element of a situation, and roundly ignore the positive, this pattern can escalate till it’s sabotaging. Humans are primed to pick up on negative cues, because they might indicate that action is required in the face of danger. So in a sense, negativity is an occupational hazard of being human – but when finding the negative colors your entire life, it starts to blur into depression. “It is striking that recent research suggests that someone with depression is less likely to visually focus on happy faces than a non-depressed person,” says psychologist Suzanne Roff-Wexler, PhD, founder of CompassPoint Consulting. “If we observed carefully, could we notice how a depressed person avoids happy faces or situations while being more ‘comfortable’ with the opposite? I wonder if someone with depression is even aware of this visual bias toward the negative.” Being a “realist” can subtly shift into being pessimistic which can subtly shift into being negative and even feeling “at home” with depression. Watch yourself for how you react to neutral or even good news – does it seem good, or do you immediately discount it because it will surely turn out poorly in your mind?
This is a critical one, because the “toggle” can be a big clue that something more serious is going on. When you’re depressed, a happy event can take you out of it, and things can seem fine, for a little while – but the depression typically returns once you acclimate to the event. “An interesting ‘symptom’ of depression that may not be well known,” says Roff-Wexler, “is when someone with depression is temporarily lifted out of that state due to a positive event, opportunity, or interpersonal connection. The depression is real and does not go away with a positive experience but it seems briefly alleviated, later to return. Think of it as toggling between being depressed and then not feeling depressed given outside circumstances.”
This is not such a subtle symptom, but is definitely worth mentioning. Depression often carries with it the comorbidity of addiction – people with depression are more likely to drink alcohol heavily, smoke, have eating disorders, and have other dependencies and addictions. After all, when you’re depressed, it’s natural to want to use the tools at your disposal to cope with it – the problem is that we’re not very good at picking healthy tools. It’s much easier to smoke and drink than to go to therapy and exercise. Of course, the former methods will ultimately make the depression worse, while the latter two will put you on track for recovery. If you notice that you’re engaging in any kind of substance or behavior more than you used to, or so much that it’s messing up your life in other ways, think seriously about talking to someone about it.
The subtler symptoms of depression definitely deserve attention if you’re experiencing any (or several) of them. Talk to a friend, or even better, reach out to a psychologist if you think you might be depressed. There’s no magic bullet for depression, but there are certainly treatments that are effective. It’s often just a matter of finding the right one, or the right combination. And remember you’re not alone: Lots of people deal with and recover from depression – and the more people talk about it, the easier the road to recovery becomes.
This article first appeared Forbes, 17 February 2015.