Depression may not always look “sad”: Many people with a depressive disorder will deny that they’re sad. Some people will report depression as “feeling blah” or “feeling nothing,” or they complain of aches and pains rather than sadness. People with depression may look as if they’re about to cry or they may have no affect (i.e., they may have a blank look). The DSM-5 says that signs to look for are “tearfulness, brooding, irritability, obsessive rumination, anxiety, phobias, excessive worry over physical health, complaints of pain.” People with depression often experience major distress; their mental and physical anguish is real.
People with depression may seem fine: People with depression may keep busy and seem functional but still have a serious condition. People with various levels of depression make a huge effort just to get through the day, but they may not talk about it. They may downplay or deny their pain to try to protect people from worrying about them. Many people with atypical depression stay busy to try to escape their grief, to distract themselves, and to protect their loved ones from worrying. People may feel guilty about (or unworthy of) the attention and concern they receive when their friends realize they’re struggling.
Depression usually feels worse than it looks: People with depression may dwell on how bad (stupid/ugly/worthless) they think they are. There is often a constant, critical internal voice tearing them down, questioning every move, second-guessing every decision. On top of that, people may feel deeply ashamed of these thoughts. People with severe depression can appear totally self-absorbed and self-involved.
Atypical depression is still a medical condition: Because positive events can make people with this condition feel temporarily better, individuals and family members may think the problem is "personal" rather than biological. They may think that if the person does these activities more often—if they just work harder to be well—they’ll feel completely better. This misunderstanding of the illness can lead family to believe that when the person’s mood drops, the person isn’t putting in enough effort. Remember: mood change is the main characteristic of atypical depression. Don’t hold the individual responsible for her return to despair.
People with depression often think about dying: Many people with severe depression want to be released from their mental anguish or believe they’re a burden, and that other people would be better off without them. It’s important to talk openly about this potentially deadly part of their condition; some people with depressive disorders will talk freely about these thoughts, and others will hide them. There is no guarantee that we can always predict whether or when someone will attempt suicide. Factors that seem to put people at high risk for suicide are: having melancholic depression or bipolar depression (particularly with psychotic features); a history of previous suicide attempts; a family history of completed suicide; and coexisting substance abuse issues. It is important to remember that there are not always warning signs; we have to ask the hard questions.
Family input is critical to a diagnosis: People with a depressive disorder may be less likely to admit the truth of how they feel because of their sense of guilt and shame. Many general practitioners miss an opportunity to diagnose someone because the person under-reports how severe their condition is. When family members also consult with the doctor, the person is more likely to get an accurate diagnosis and the help they need. The DSM-5 Criteria for Depressive Disorders actually requires that the healthcare professional making the diagnosis ask for “outside” verifying information to make a correct diagnosis—that is, the family’s input. So insist on your right to contribute information to the diagnostic process.