By Rev. Wambui Njoroge, M.Sc.
Statistics on Depression: The World Health Organization reports that an estimated 21.0 million adults in the United States had at least one major depressive episode in 2020. This represented 8.4% of all U.S. adults. Depression is highest among those aged 18-19 (21%). The lowest is age 30-44 (16.8%). In comparison, the country with the most depressed people is Afghanistan, where more than 1 in 5 people suffer from depression. The country considered to have the best mental wellbeing is Sweden. If you want to decrease your chances of being depressed, one can move to Sweden. Compared to men, women are nearly as twice as likely as men to be diagnosed with depression. Research literature accounts for the issues of women by citing normal hormonal changes, that is in addition to other psychosocial stressors.
How about culture that has the highest rate of depression? Untreated depression if prevalent in majority Black and Hispanic communities, which leads to unnecessary suffering. Equally, the rates of treatment for major depression are lowest in Hispanic communities and lower in Black communities than in White communities. This information is helpful to mental health providers in addressing issues of prevention, diagnoses, and intervention.
Imagine when there was no depression, or we did not know about it. Those Immigrants who argue that in Africa folks did not know so many people who were depressed are right. For example, it is unlikely that there were less people suffering from Seasonal Affective Disorder that is diagnosed among people who live in extremely cold climates, with less sunshine. Then again, even more recent, COVID-19 and its variants have triggered many causes of depression. Practically COVID-19 has put depression in the center of daily conversations. Yet, there is one depressive disorder that is not in the DSM but that has been observed in clinical settings. This is Smiling depression (SD). Let us see what SD is, the causes, the symptoms, how does it look like, and why is it hard to diagnose. What can one do?
What is it? Smiling depression describes someone living with depression on the inside while appearing perfectly happy on the outside. Research indicates that it is possible for a person to suffer, and not know they have depression. I remember clinical notes highlighted in the process recording that read like this, “Is this person aware of their diseases or not.” Many times, it was marked, “Denies knowing.” Yet, there are many occasions that a person does not know that they are depressed. However, one may sense that something is just not right, but is not able put a finger on it. That is how complex human beings are.
Causes of SD: This type of depression is caused by all the other factors that play a role in the onset of depression. It could be vulnerability to illnesses from internal factors like body chemistry, physical health, traumatic injuries, and heredity that act together with external factors. One time in our Zoom service with partners from Kenya and U.S. we discussed some specific depressive moods that are likely to be experienced more by women than men. We noted that there are developmental phases in the life of a woman that are influenced by hormones. From young adults who are of childbearing age, to adulthood and Older Adults who are experiencing pre-menopausal symptoms, or symptoms due to possible declining health. In most cultures, although these developmental issues trigger depression, they are not a disease. Women are not expected to seek any treatment. Nevertheless, considering the number of women who are in the workforce, it has become increasingly commonplace for women to seek relief to alleviate depressive symptoms. Women can no longer afford to stay at home and wait out for their health to decline without medical support or improve with the same medical support. Therefore, it is important for professionals who work with women in any capacity to be aware of these developmental phases.
Symptoms of SD: The symptoms for SD are the same as for other depressive moods. These have been previously noted as changes in appetite-lack of appetite or overeating, excessive weight gain, or weight loss without trying to lose weight, lack of sleep, difficulty sleeping, falling asleep or remaining asleep, or it could be oversleeping. Feeling fatigued and lethargic, without the presence of any sickness, feelings of hopelessness, lack of self-esteem, and low self-worth. People may also have suicidal ideation. Loss of interest or pleasure in doing things that a person once enjoyed, including intimacy for couples.
What Does it look like? This is a situation where it seems that people “wear a mask.” Whether one is aware of being depressed or not. As a result, it is difficult for their loved ones to know that they are depressed. SD individuals may function highly, so that it is not obvious that a person is depressed. There are people who are genuinely happy most of the time, and who laugh often. The type of people who can be described as overly optimistic. This does not mean that they have a disorder, or they are suffering from depression. The behavior manifestation could be intentional or unintentional.
How Can you tell? It is not easy at all to diagnose someone with SD. It reminds me of that saying, “know yourself.” A person with smiling depression might appear on the outside as very well put together. This is a well-functioning individual, hardworking, and these overcompensating factors, makes it more difficult to determine the symptoms of depression. Family and relatives that live close to the individual may be able to tell and even suspect the presence of SD. However, as with any need for medical attention, the individual suffering from SD is responsible for making that call.
Why is SD Hard to Diagnose? One of the reasons is because it is not included in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). There is no listing of criterial that helps professionally and conclusively diagnose SD. However, since it has been observed by therapists and counselors, in the future, it maybe be diagnosed as a major depressive disorder with atypical features (online healthline.com). Individuals suffering from SD may be aware something is wrong, and may hide their depression, mainly for fear of being judged, labeled, or being stigmatized. Let us see what our own two Clinicians had to say in the Mental Health Stars WhatsApp Forum:
Dr. Pacificah, Psychiatric Nursing Practitioner: noted: “(This smiling depression apparently does affect a huge population. People walking, smiling, laughing but inside they are suffering. people tend to hide from bringing it out because nobody wants to be called a failure or a pretender or whatever, the society is good at pointing fingers instead of helping. I have encountered cases where I am told the struggle has been for years for the sake of the kids: talking about 25+years of struggling couples. Or if it is kids, they do not want to share because of fear, thus they keep smiling outside, while on the inside they are totally torn apart. These people do experience all the symptoms of depression, but they manage to hide them from everyone.)”
Dr Pauline Waweru, Psychotherapist wrote: “Smiling depression is very common. This is a situation where people “wear a mask” and it’s difficult for their loved ones to know that they are depressed. They might appear perfectly okay on the outside, but then when they are alone, they are sad, hopeless, and helpless. They might also appear cheerful and happy from the outside but cry a lot when they are alone. Most of them can hide their depression, mainly for fear of being judged or being stigmatized. Some might also wear a facade of happiness because there is someone they are trying to protect. These are people who might appear okay during the week but spend their weekends isolating from others.”
What Next? If you or someone you know is suffering from depression, seek the help of a Mental Health provider-a counselor, therapist, psychologist, psychotherapist, or a psychiatrist. The later is a medical doctor who during residency selected psychiatry as their practice. Sometimes folks just call all mental health professionals and providers “counselors.”
Resources/includes notes from previous articles.
Access More resources Online in the public domain/through websites of WHO, CDC, Nami.
Disclaimer: The information shared here should never be a substitute for your treatment plan agreed upon with your doctor. You are encouraged to follow up with all activities prescribed for your mental wellbeing, including taking meds and reporting any negative side effects. You should not stop or adjust your dosage without consulting with your doctor or treatment team.
Rev. Wambui Njoroge is a freelance write with Kenyan Parents USA, Mental Health Stars, Association, Incorporated. She writes on issues of prevention and intervention that affect individuals or families in the areas of family life, education, health, religion, and politics.
