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smiling depression

Smiling Depression: Masking the Pain

Smiling depression isn’t an oxymoron. It’s a serious atypical manifestation of depression in which the sufferer masks typical depressive symptoms like sadness and lethargy with the outward appearance of a happy, successful, productive life. While approximately 10 percent of the U.S. population suffers from depression, not all sufferers experience it in the same way. Typically, depression is associated with a deep sense of sadness, despair, and lethargy, a figurative and sometimes literal inability to get out of bed that depletes energy and impacts all aspects of life. In contrast, someone living with smiling depression feels the same sadness inside but is able to function normally and present a facade of contentment and happiness to the outside world.

Smiling depression is not a clinical or official diagnosis; it is most often diagnosed as atypical depression. It is not the same as high-functioning depression, which is similar to common depression but is less severe, enabling people to function almost normally despite persistent sadness and low energy but without the cheerful external appearance that characterizes smiling depression.

Smiling depression presents unique challenges not the least of which is a diagnosis. Family and friends may be unable to spot the signs of depression and sufferers often do not themselves admit to a problem. After all, if I have a “put-together” life – a stable relationship, good friends, satisfying work, no financial worries – what reason do I have to feel sad? The result might be guilt about their real feelings and shame that prevents them from acknowledging their unhappiness to anyone.

A further serious consideration in dealing with smiling depression is increased vulnerability to suicide. While typical depression saps energy and its sufferers may lack the ability to act on suicidal intentions, those with smiling depression who have the strength to go about their daily lives despite inner feelings of hopelessness may also have the energy and motivation to follow through on such thoughts. When people in the public eye die by suicide, the shock that follows is often a consequence of the facade that has masked the depression, often for years. The danger presented by smiling depression makes it critical to be aware of who is at risk and of signs and symptoms – in oneself or others – so treatment can begin expeditiously.

The Cause of Smiling Depression

There is no specific cause of smiling depression. Sometimes it is triggered by an event – the loss of a job or relationship or a sense of purpose and meaning in one’s life – or it may be a constant state that is unrelated to any specific factor. Those in a cultural or family environment that stigmatizes the expression of negative feelings as a weakness (“Just get over it!”) may be more likely to put on a happy face and keep their real feelings to themselves. This is often particularly true for men who are subject to constraining ideas about masculinity and are less likely than women to seek help for emotional problems. Temperament can be a factor in the propensity to develop smiling depression. It has been linked to those who tend to perfectionism, who have unrealistic expectations – set by themselves or others – for their own lives, and who dwell on every small failure or embarrassment as an indication of worthlessness.

The distinguishing symptom of depression — deep, prolonged sadness – may be successfully masked by someone with smiling depression but other symptoms may be present: changes in appetite, sleep, lack of self-esteem and self-worth. The inability to find pleasure doing things that were once enjoyed, another hallmark of typical depression, may also not be present in those with smiling depression. They may in fact show pleasure outwardly and then return to a general state of sadness when alone. They may feel that expressing their true feelings would burden those around them or they may genuinely believe that their active, apparently happy lives mean that they’re fine. But someone with smiling depression isn’t fine and isn’t likely to improve without treatment by a mental health professional.

Treatment for smiling depression is generally similar to that for other manifestations of depression – a combination of lifestyle changes, medication, and psychotherapy. In any form, depression is a difficult and enervating condition but taking the first steps – by acknowledging the problem and seeking help – has put millions of people on the road to recovery.

Alex Dimitriu, MD, is double board-certified in psychiatry and sleep medicine and is the founder of the Menlo Park Psychiatry and Sleep Medicine Center in Menlo Park, CA.

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