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She walks confidently into work, smiling and greeting people. She’s competent. She goes out to get coffee for a coworker and herself and chats for a while, tells a joke or two.

She's also depressed, suffering from a condition known as “smiling depression" that puts her at a higher risk for suicide.

“The public thinks of depression as an illness always characterized by symptoms of depression,” but a depressed appearance isn’t always there, said Dr. Joseph Fanelli, a psychiatrist at the Behavioral Health Services program of Community Healthcare System at St. Catherine Hospital in East Chicago.

Though smiling depression has become a common term, it’s not found in the Diagnostic and Statistical Manual of Mental Disorders. Instead it’s in the category of atypical depression, Fanelli said. “There are a lot of ways people can smile and still be very severely depressed. They can be very down in the beginning of day, then like clockwork their mood improves and by evening they may not feel depressed at all.”

People with smiling depression are socially appropriate. “People will have a ‘false self,’ looking fine and even feeling happy with that public face,” said Julia Kocal, who has a doctorate in psychology, is a certified Health Service Provider in Psychology, and a member of LaPorte Physician Network in Knox.

“To others, (the depression) is not recognizable because the person is not sharing what’s really going on," said Tamara Miller, a clinical psychologist at Samaritan Counseling Center in Michigan City. "They may be high-functioning and hide it well and seem confident. Some with smiling depression don’t even realize they’re depressed.”

A key symptom of smiling depression is anhedonia — loss of pleasure in favorite things, Fanelli said. He said there are 10 to 12 symptoms people can have, including irritability, especially in older adults; change in sleep patterns, insomnia or sleeping too much; loss of appetite or overeating; and restlessness.

“They’re not in bed all day, but they just don’t care about anything. They may have been taught to smile, but they don’t want to socialize,” Kocal said.

Sufferers also may have a low sex drive, feelings of loneliness and despondency, lack of motivation, anxiety, guilt. “But that doesn’t make them alarmed. They may be forgetful about appointments and conversations and wonder if they have dementia,” Kocal said. “If you’re smiling, going to football games, seeming happy, no one knows your turmoil, your emptiness.”

And that increases the risk of suicide, according to health professionals. “The more they try to hide (their depression), the more painful it is. If they recognize it and are not asking for help, that makes them more vulnerable because they’re ashamed. And they have more energy (than the typically depressed), enough to follow through with suicide,” said Miller.

"They may not have a plan for suicide, but it’s the way they feel," Kocal said. So "they don’t get the help they need.” 

“One reason for suicide among some with atypical depression is that they find themselves crashing very abruptly. It’s not how low you go but how fast you get there,” Fanelli said.

Kocal said it can help to connect with someone when something seems amiss. “Saying ‘You look sad, can I help?’ makes the person feel more like they’re not alone.” Family members who see their kin show little interest in something they’d usually be passionate about “can say, ‘I love you.' 'You don’t seem yourself.' 'You’re not excited the way you used to be.' 'I’m just wondering if maybe you could be clinically depressed. Maybe talk with your doctor about that.’ It can awaken the person to think, a ha, maybe that’s it, or, I thought I was hiding it better,” Kocal said.

She said someone with smiling depression may say they’re fine, yet feel like a burden or think the family would be better off if he or she were dead. “They may know that’s not really true and that realization (from someone asking how they are) can shift from being fake to having an authentic conversation that validated them, that they are needed,” Kocal said.

Fanelli said it’s important that someone with atypical depression be screened  by a health care professional. Once diagnosed, treatment can include psychotherapy, medication and other things such as bright light therapy commonly used for seasonal affective disorder. “Treatment is highly successful," Fanelli said.

Don’t be afraid to ask if someone is thinking of self-harm, Miller said. “Talking to them about it is not going to encourage it. Instead it will be encouraging for someone to know you’re there for them.”

Even if the person denies suicidal intention and possibly takes offense, “If you lose a friendship over it or it stresses the relationship, then you sacrifice that for (their sake),” Miller said.

If you or someone you know is thinking about suicide, call the confidential National Suicide Prevention hotline: 800-273-8255.

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