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In today's world of chaos and stressful life dealing with situations alone with no family, friends or financial support makes people vulnerable to developing depression. It is a worldwide major public health problem and "Smiling depression" a.k.a. atypical form of depression is on the rising trend. People wear masks to prevent the inner turmoil and the need to overcome it. Mostly, this affects the middle-aged cohort-the working force for any nation. It significantly leads to morbidity, disability, mortality and ultimately, socioeconomic loss. Addressing this type of depression at an early stage will not only help in reducing self-harm and suicides but will also improve the quality of life of those affected. Both pharmacological and non-pharmacological treatments can be provided in different settings by people in either health or non-health professionals. Health system strengthening through proper counseling and psychotherapy, appropriate referral mechanisms, and continuity of care is the point of need to tackle this escalating concealed problem.
INDIAN JOURNAL OF COMMUNITY HEALTH / VOL 31 / ISSUE NO 04 / OCT - DEC 2019 [Smiling depression ] | Bhattacharya S et al
“Smiling depression” (an emerging threat): Let’s Talk
Sudip Bhattacharya1, Kyle Hoedebecke2, Neha Sharma3, Ozden Gokdemir4, Amarjeet Singh5
1Assistant Professor, Department of Community Medicine, Himalayan Institute of Medical Sciences, Swami Ram
Himalayan University, Dehradun, Uttarakhand, India; 2Medical Director, Oscar Health, United States of America,
3Assistant Professor, Department of Community Medicine, Himalayan Institute of Medical Sciences, Swami Ram
Himalayan University, Dehradun, Uttarakhand, India; 4Assistant Professor Dr, PhD Izmir University of Economics,
Faculty of Medicine, Izmir, Turkey;5Professor and Head, Department of Community Medicine, Post Graduate
Institute of Medical Education & Research, Chandigarh, India
Corresponding Author
Corresponding Author: Dr Sudip Bhattacharya, Assistant Professor, Department of Community
Medicine, Himalayan Institute of Medical Sciences, Swami Ram Himalayan University,
Dehradun, Uttarakhand, India
E Mail ID:
Bhattacharya S, Hoedebeck K, Sharma N, Gokdemir O, Singh A. “Smiling depression” (an emerging threat): Let’s
Talk.Indian J Comm Health. 2019;31(4):433-436.
Source of Funding: Nil Conflict of Interest: None declared
Article Cycle
Received: 13/11/2019; Revision: 15/12/2019; Accepted: 25/12/2019; Published: 31/12/2019
This work is licensed under a Creative Commons Attribution 4.0 International License.
In today’s world of chaos and stressful life dealing with the situations alone with no family, friends or financial
support makes people vulnerable to developing depression. It is a worldwide major public health problem and
“Smiling depression” a.k.a. atypical form of depression is on the rising trend. People wear masks to prevent the
inner turmoil and the need to overcome it. Mostly, this affects the middle-aged cohort - the working force for any
nation. It significantly leads to morbidity, disability, mortality and ultimately, socio-economic loss. Addressing this
type of depression at an early stage will not only help in reducing self-harm and suicides but will also improve the
quality of life of those affected. Both pharmacological and non-pharmacological treatment can be provided in
different settings by people in either health or non-health professionals. Health system strengthening through
proper counselling and psychotherapy, appropriate referral mechanisms, and continuity of care is the point of
need to tackle this escalating concealed problem.
Depression; mental health; pain
Depression is a common, yet often neglected public
health problem and mood disorder that negatively
affects more than 300 million people globally.
Individuals suffering from depression often
experience constant sorrow, hopelessness, and
anhedonia, or unable to enjoy normally pleasurable
experiences. Besides the emotional components,
depressive disorders possess somatic components
that often impede an accurate diagnosis. These
symptoms range from chronic pain, digestive issues,
respiratory problems, and cardiac problems. For this
reason, we have to consider it carefully within a list
of differential diagnoses.(1,2,3)
As per Diagnostic and Statistical Manual of Mental
Disorders-V (DSM-V) criteria the person must have 5
or more symptoms (major) (Table-1) during the same
2-week period. In addition to this, he/she must
present as depressed mood, loss of interest, or
INDIAN JOURNAL OF COMMUNITY HEALTH / VOL 31 / ISSUE NO 04 / OCT - DEC 2019 [Smiling depression ] | Bhattacharya S et al
Recently, psychiatrists report a new type of patient
suffering from depression but without the classical
clinical features. Researchers have coined the name
“smiling depression” or “masked depression,” where
an individual may live with unrecognized or
undiagnosed depression due to the facade of
appearing perfectly happy or content.(5,6,7)
Smiling depression, or masked depression, is not
officially recognized in the DSM-5, but is often
diagnosed as major depressive disorder with
atypical/uncommon features in clinical settings.(7)
Smiling depression presents with atypical features
compared to those of classic depression -
complicating the process of diagnostic process and
hindering the initiation of treatment(8)
Still other difficulties with diagnosing smiling
depression are that many may not even realize that
they are depressed or they don’t seek help.(9)
Those suffering from smiling depression stun others
when they commit suicide. This is due to the masks
or smiles they wore in their face. One of the
most famous recent examples is that of actor and
comedian Robin Williams unexpected
Thus, people living with smiling depression may
appear perfect from the outside; k however, the
experience the distressful symptoms of depression
internally, complicating the evaluation and
treatment. Generally, an individual with smiling
depression may display the following features
externally (12,13):
An active, high-functioning individual
Someone holding a good position professionally,
with a good work life balance
A person appearing to be cheerful, optimistic,
and generally happy
However, the following clinical features can provide
better insights about individuals with smiling
depression (14):
An in-depth understanding of the
developmental history to exclude
neurodevelopmental disorders which may
have lasting impacts on psychiatric well-being
Attitude of the patient, for example, stigma, or
avoidance of discussions related to depression
or mental health, which may lead to under-
Psychologic features, personality profile, and
family history related to neuropsychiatric
Physical examination to evaluate other co-
morbidities potentially associated with the
appearance of happiness despite ongoing
health problems
Sources and reasons of referral, which may
provide insights on chronic and undiagnosed
neuropsychiatric conditions
Age distribution (2278 yrs old at onset of
illness) and sexual orientation (female: male
ratio of 2.5:1)(15)
Suicidal thoughts are common among those
suffering from major depression, but many do not
have enough motivation or energy needed to act on
these thoughts. In the case of smiling depression, the
person has the energy and motivation to act upon
suicidal thoughts. Due to this, the risk of suicide may
actually be higher and more difficult to prevent
among individuals with smiling or masked
Common risk factors
Life changing events - As with other types of
depression, smiling depression can be triggered by a
situation such as a break up, loss of a job, or death of
a loved one.
Variability of individual judgment - Culturally,
people deal with and experience depression
differently including suffering more somatic
(physical) symptoms than emotional ones.
Researchers believe these differences may have to
do with internally versus externally oriented
thinking, if one’s thinking is externally oriented;
he/she may not focus on the inner emotional state,
but instead may experience more physical
symptoms. As an example, a person may suffer from
abdominal pain (i.e. irritable bowel syndrome)
associated with depression and tends to focus on
pain itself while ignoring the emotional components.
In some cultures, the stigma of depression has a
varying impact. For example, expressing emotions
may be seen as “attention seeking” or showing
weakness. This can be especially true for men under
scrutiny for their masculinity who may have been
subjected to machismo viewpoints in that “real men”
don’t cry. As a result, men are less likely than women
to seek mental health services.(16) Those who feel
they would be judged for expressing depressive
INDIAN JOURNAL OF COMMUNITY HEALTH / VOL 31 / ISSUE NO 04 / OCT - DEC 2019 [Smiling depression ] | Bhattacharya S et al
symptoms would be more likely to put on a facade
and keep it within themselves.
Social media - Users of social media (SM) who share
online content with others often observe others’
behaviour and compare that to their own. Some
users present an identity that deviates from their
true self by sharing only a happy aspect of life,
resulting in a dichotomy between inner anguish and
outer cheerfulness. This is when cases of smiling
depression may emerge. A study reported that a
significant relationship between a happy self-
representation or exciting content exists with those
feeling depressive symptoms.(17,18)
According to Rogers’s theory of self and
personality- “we want to feel, experience and
behave in ways which are consistent with our self-
image and which reflect what we would like to be
like, our ideal self. The closer our self-image and
ideal-self are to each other, the more consistent or
congruent we are and higher our sense of self-
worth.” A mismatch between the real self and the
ideal self is common among the persons trying to
escape their current existence by creating a fictitious
sense of a pleasant personal or family life.(19) For
example, the SM self appears to be more socially
acceptable or attractive with families and
individuals. We never post our failures on Facebook
so as to maintain our social status.
Many people may not be willing or able to post
pictures when they are at their worst, instead opting
to share only their good moments with the world.
This can create a void of realness that gives smiling
depression more room to grow.
Expectations - Unrealistic expectations of ourselves
to be better or stronger is common among us as well
as we are also affected by outside expectations
even co-workers, parents, siblings, children, or
friends can develop smiling depression.
Due to the pressure of unrealistic expectations, we
may be more likely to want to hide our feelings if
they do not seem to serve those expectations. A
perfectionist might be even more at risk; due to the
impossibly high standards they hold himself or
Implications of smiling depression in
Public Health
Depression, whether it is major or minor, leads to
acute and chronic mental health challenges and poor
quality of living. For these reasons, it is essential to
understand how smiling depression can affect
individuals, families, communities, institutions, and
the health systems at a large.
At the individual level, smiling depression affects the
mental wellbeing of the individuals - resulting in
reduced productivity and poor quality of living.
Moreover, chronic smiling depression may lead to
unhealthy behavior like substance abuse or unsafe
sexual practices, which may have adverse health
consequences. In addition, smiling depression often
goes under-reported due to its nature and remains
beyond the scope of psychiatric diagnosis and
management. Therefore, by the time someone is
diagnosed with smiling depression, other physical
and mental comorbidities may exist affecting the
overall health status of the affected individuals.
At the family and household level, the interpersonal
relationships may be affected due to mismatched
external and internal conditions. The affected
individuals may suffer from relationship crises and
inadequate emotional bonding with the closed ones.
These challenges may affect the wellbeing of families
and households in a silent way.
At the community level, the healthcare workers may
not have the skills and expertise to diagnose smiling
depression. In addition, stigma related to mental
illness is a major problem particularly in low and
middle income countries. Therefore, the hidden
burden of smiling depression can be poorly assessed
and alleviated at the community level.
In the institutional settings, healthcare providers
may miss smiling depression due to its varying
presentation. However, treating any health
conditions offer an opportunity to discuss if the
patient(s) experienced any depressive conditions in
the past and assess if s/he needs any further
evaluation or treatment. Depression is common
among global populations; therefore, institutional
approaches to depression can be helpful if they
become proactive in addressing smiling depression
as well.
At the systems level, smiling depression may hinder
the overall wellbeing and economic growth of a
nation. The more challenging aspect is a lack of
empirical and representative data on smiling
depression, which can help in understanding the
severity at the population level. In resource-
constrained contexts, smiling depression may be
poorly acknowledged at the systems and policy level
as critical infectious and chronic diseases are often
prioritized leaving underreported problems like
smiling depression behind in the policy discourses.
INDIAN JOURNAL OF COMMUNITY HEALTH / VOL 31 / ISSUE NO 04 / OCT - DEC 2019 [Smiling depression ] | Bhattacharya S et al
Conclusion and Recommendations
It is essential to acknowledge the hidden burden of
smiling depression at the individual and population
levels. In addition, healthcare providers, social
workers, researchers, policymakers, and other key
stakeholders should consider the severity of smiling
depression and how it may affect the overall
wellbeing at the micro and macro levels. While it is
critical to strengthen the capacities of the healthcare
providers and institutions to diagnosis and treat
smiling depression, preventive measures should be
taken to reduce stigma on mental illness and enable
individuals and their caregivers to share problems no
matter how minor it may appear initially. To create a
truly healthy and happy society, the sufferings
underlying smiling faces should be addressed with
scientific and holistic approaches.
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1. Depressed mood most of the day, nearly every day.
2. Markedly diminished interest or pleasure in all, or almost all, activity most of the day, nearly every day.
3. Significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day.
4. A slowing down of thought and a reduction of physical movement (observable by others, not merely subjective
feelings of restlessness or being slowed down)
5. Fatigue or loss of energy nearly every day.
6. Feelings of worthlessness or excessive or inappropriate guilt nearly every day.
7. Diminished ability to think or concentrate, or indecisiveness, nearly every day.
8. Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific
plan for committing suicide.
... Esto nos lleva a reflexionar sobre las personas que pueden mirarse perfectamente bien en el exterior, es decir, actúan con normalidad y no se ven deprimidos, más bien se les ve fuertes, entusiastas, alertas, determinados, activos, inspirados, lo que implica un manejo socialmente aceptable de su depresión. No obstante, esto no significa que no vivan emociones negativas, ya que internamente experimentan los angustiosos síntomas de la depresión, lo que complica la evaluación y el tratamiento (Bhattacharya, Hoedebecke, Sharma, Gokdemir & Singh, 2019). ...
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Se contrastan las diferencias en sintomatología depresiva entre mexicanos de dos polos urbanos importantes, analizando la predicción de la depresión a partir de los perfiles afectivos y variables sociodemográficas. Método. Participaron 1036 estudiantes, 431 del centro de México y 605 del noreste. Se evaluó la sintomatología depresiva mediante el CES-D-20 y perfil afectivo con el PANAS-20. Resultados. Hay una alta prevalencia de sintomatología depresiva en los participantes, con diferencia significativa entre los grupos. En el grupo del centro la depresión es predicha por el perfil de afecto autodestructivo, afecto alto, así como hábitos no saludables, mientras que en el noreste coincide en los primeros dos predictores diferenciándose porque se incorpora en el modelo el menor sentido de autorrealización. Conclusión. Nuestro estudio sugiere diferencias en la manifestación de la depresión por zona geográfica, con un perfil afectivo autodestructivo y de afecto alto. Es de interés resaltar que el perfil afectivo alto puede enmascarar la forma de manifestar la depresión, ya que se les puede considerar como personas extrovertidas y por tanto, subestimar el malestar emocional que puedan estar presentando. Este aspecto es fundamental en la mejor comprensión de la depresión en el campo clínico.
... A lot of studies on depression implied that depressed people show less facial expressivity, such as the absence of a smile. Nevertheless, masked depression (smiling depression) is a type of depression with atypical syndromes, where individuals may seem perfectly happy and smiling [11], [12]. Thus, capturing the smile lines in facial features (2D or 3D) is not as effective as it seems for predicting depression against what is suggested in [13]. ...
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Background: Depression diagnosis requires five or more symptoms (Diagnostic and Statistical Manual of Mental Disorders-DSM-5). One of them must be either Depressed mood or Anhedonia, named main criteria. Although the secondary symptoms can be divided into somatic and non-somatic clusters, the DSM-5 identify depression in all or none fashion. In contrast, depression severity is a continuous variable. Therefore, it is commonly assessed with scales such as the Hamilton Depression Rating Scale (HAMD). Previously, we reported that patients with moderate depression (MD) exhibit greater impairments in cardiac-autonomic modulation than severely depressed (SD) patients. However, clinicians usually do not use scales. Objective: To verify whether the DSM-5 symptoms would be able to discriminate SD from MD and MD from non-depressed (ND) subjects. Material and Methods: Depression was diagnosed based on the Structured Clinical Interview for DSM-5® Disorders. The HAMD evaluated depression severity. In depressed subjects, MD and SD were defined considering the HAMD scores. ND was defined considering both the absence of DSM-5 criteria for depression and the HAMD score. Among 782 outpatients, 46 SD were found. MD and ND subjects were randomly sampled to match the demographic variables of the SD group. Results: Discriminant analysis showed that Depressed Mood was the most reliable symptom to discriminate ND from MD. Anhedonia discriminated SD from MD. Among the secondary DSM-5 criteria, the somatic cluster discriminated ND from MD and the non-somatic cluster SD from MD patients. Discussion: The presence of the somatic cluster in MD may indicate decreased vagal tone and/or increased sympathetic tone, leading to higher cardiovascular risk. As SD is associated with the non-somatic cluster, these patients are at risk of committing suicide. The DSM-5 symptoms exhibited by the patient may help the choice of adequate pharmacological treatment. This would avoid the use of antidepressants that unnecessarily increase cardiac risk in MD. When the symptom cluster suggests SD, the treatment must focus on the prevention of suicide. Conclusions: Depression severity may be inferred based on the DSM-5 criteria. The presence of the Anhedonia main criterium accompanied by non-somatic criteria indicate SD. The Depressive Mood criterium followed by somatic criteria suggest MD.
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Background Masked depression is often misdiagnosed due to the predominance of somatic symptoms and is further complicated by lack of awareness among doctors. Aim The present survey was conducted to gather the views of psychiatrists and nonpsychiatrists regarding presentation and management aspects of masked depression. This may help in unmasking this condition and facilitate early identification and appropriate management of patients presenting with this condition. Materials and Methods This questionnaire-based survey was conducted as an interview through computer-aided telephonic interview among 300 doctors (150 psychiatrists and 150 nonpsychiatrists) across India. Results Both psychiatrists and nonpsychiatrists reported a high prevalence of somatic symptoms among patients with masked depression. Nonpsychiatrists (44%) more often than psychiatrists (20%) noted chronic pain in the majority of patients with masked depression. Psychiatrists (31%) more often than nonpsychiatrists (9%) noted lack of concentration in the majority of patients with masked depression. Sexual dysfunction among young patients and noncompliance to therapy for chronic illness were considered as potential predictors of masked depression. There was a general agreement among psychiatrists and nonpsychiatrists that medical liaising is beneficial for the management of patients with masked depression. Conclusion Both psychiatrists and nonpsychiatrists agree that somatic symptoms are commonly encountered in patients with masked depression. However, these somatic symptoms are often interpreted as physical illness rather than as an entity of depression which creates an unmet need in terms of managing masked depression, especially by nonpsychiatrists.
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Recent epidemiological surveys conducted in general populations have found that the lifetime prevalence of depression is in the range of 10% to 15%. Mood disorders, as defined by the World Mental Health and the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, have a 12-month prevalence which varies from 3% in Japan to over 9% in the US. A recent American survey found the prevalence of current depression to be 9% and the rate of current major depression to be 3.4%. All studies of depressive disorders have stressed the importance of the mortality and morbidity associated with depression. The mortality risk for suicide in depressed patients is more than 20-fold greater than in the general population. Recent studies have also shown the importance of depression as a risk factor for cardiovascular death. The risk of cardiac mortality after an initial myocardial infarction is greater in patients with depression and related to the severity of the depressive episode. Greater severity of depressive symptoms has been found to be associated with significantly higher risk of all-cause mortality including cardiovascular death and stroke. In addition to mortality, functional impairment and disability associated with depression have been consistently reported. Depression increases the risk of decreased workplace productivity and absenteeism resulting in lowered income or unemployment. Absenteeism and presenteeism (being physically present at work but functioning suboptimally) have been estimated to result in a loss of $36.6 billion per year in the US. Worldwide projections by the World Health Organization for the year 2030 identify unipolar major depression as the leading cause of disease burden. This article is a brief overview of how depression affects the quality of life of the subject and is also a huge burden for both the family of the depressed patient and for society at large.
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Gender differences in mental disorders, including more anxiety and mood disorders among women and more externalizing disorders among men, are found consistently in epidemiological surveys. The gender roles hypothesis suggests that these differences narrow as the roles of women and men become more equal. To study time-space (cohort-country) variation in gender differences in lifetime DSM-IV mental disorders across cohorts in 15 countries in the World Health Organization World Mental Health Survey Initiative and to determine if this variation is significantly related to time-space variation in female gender role traditionality as measured by aggregate patterns of female education, employment, marital timing, and use of birth control. Face-to-face household surveys. Africa, the Americas, Asia, Europe, the Middle East, and the Pacific. Community-dwelling adults (N = 72,933). The World Health Organization Composite International Diagnostic Interview assessed lifetime prevalence and age at onset of 18 DSM-IV anxiety, mood, externalizing, and substance disorders. Survival analyses estimated time-space variation in female to male odds ratios of these disorders across cohorts defined by the following age ranges: 18 to 34, 35 to 49, 50 to 64, and 65 years and older. Structural equation analysis examined predictive effects of variation in gender role traditionality on these odds ratios. In all cohorts and countries, women had more anxiety and mood disorders than men, and men had more externalizing and substance disorders than women. Although gender differences were generally consistent across cohorts, significant narrowing was found in recent cohorts for major depressive disorder and substance disorders. This narrowing was significantly related to temporal (major depressive disorder) and spatial (substance disorders) variation in gender role traditionality. While gender differences in most lifetime mental disorders were fairly stable over the time-space units studied, substantial intercohort narrowing of differences in major depression was found to be related to changes in the traditionality of female gender roles. Additional research is needed to understand why this temporal narrowing was confined to major depression.
We used event-related potentials (ERPs) to explore the influence of manipulating facial expression on error monitoring in individuals. The participants were 11 undergraduate students who had been diagnosed with minor depression (MinD). We recorded error-related negativity (ERN) as the participants performed a modified flanker task in 3 conditions: Duchenne smile, standard smile, and no smile. Behavioral data results showed that, in both the Duchenne smile and standard smile conditions, error rates were significantly lower than in the no-smile condition. The ERP analysis results indicated that, compared to the no-smile condition, both Duchenne and standard smiling facial expressions decreased ERN amplitude, and ERN amplitudes were smallest for those in the Duchenne smile condition. Our findings suggested that even brief smile manipulation may improve long-term negative mood states of people with MinD.
Administered Children's Depression Scale to 27 African-American adolescents in public school for severely emotionally disturbed adolescents and to 51 junior high school regular education African-American students. Findings indicated that maladaptive students manifested higher degrees of clinical depression than did adaptive students. Findings have implications for treatment of clinically depressed children previously diagnosed as having maladaptive behaviors. (NB)
To evaluate the association between social networking site (SNS) use and depression in older adolescents using an experience sample method (ESM) approach. Older adolescent university students completed an online survey containing the Patient Health Questionnaire-9 depression screen (PHQ) and a weeklong ESM data collection period to assess SNS use. Participants (N = 190) included in the study were 58% female and 91% Caucasian. The mean age was 18.9 years (standard deviation = .8). Most used SNSs for either <30 minutes (n = 100, 53%) or between 30 minutes and 2 hours (n = 74, 39%); a minority of participants reported daily use of SNS >2 hours (n = 16, 8%). The mean PHQ score was 5.4 (standard deviation = 4.2). No associations were seen between SNS use and either any depression (p = .519) or moderate to severe depression (p = .470). We did not find evidence supporting a relationship between SNS use and clinical depression. Counseling patients or parents regarding the risk of "Facebook Depression" may be premature.
Background: Depression is common and frequently undiagnosed among college students. Social networking sites are popular among college students and can include displayed depression references. The purpose of this study was to evaluate college students' Facebook disclosures that met DSM criteria for a depression symptom or a major depressive episode (MDE). Methods: We selected public Facebook profiles from sophomore and junior undergraduates and evaluated personally written text: "status updates." We applied DSM criteria to 1-year status updates from each profile to determine prevalence of displayed depression symptoms and MDE criteria. Negative binomial regression analysis was used to model the association between depression disclosures and demographics or Facebook use characteristics. Results: Two hundred profiles were evaluated, and profile owners were 43.5% female with a mean age of 20 years. Overall, 25% of profiles displayed depressive symptoms and 2.5% met criteria for MDE. Profile owners were more likely to reference depression, if they averaged at least one online response from their friends to a status update disclosing depressive symptoms (exp(B) = 2.1, P <.001), or if they used Facebook more frequently (P <.001). Conclusion: College students commonly display symptoms consistent with depression on Facebook. Our findings suggest that those who receive online reinforcement from their friends are more likely to discuss their depressive symptoms publicly on Facebook. Given the frequency of depression symptom displays on public profiles, social networking sites could be an innovative avenue for combating stigma surrounding mental health conditions or for identifying students at risk for depression.
Major depression may be the most common medical or psychiatric disorder seen in primary medical care clinics, occurring in approximately 6 to 10 percent of the clinic populations. Despite this high prevalence rate, patients with depression often go undiagnosed or are misdiagnosed. The evidence suggests a multifactorial etiology for this problem. Many patients with depression selectively focus on the somatic components of their depressive syndrome and minimize or even deny affective and cognitive symptoms. Depression and medical disorders also often occur concomitantly with depression causing amplification of somatic complaints. Due to the unidimensional focus on the biomedical model many physicians only evaluate and treat the physical illness and do not diagnose the depression. This often leads to aggressive medical testing and treatment that carries the risk of iatrogenic injury (polysurgery, multiple tests and procedures, prescription of opiates and benzodiazepines). Several interventions are suggested to improve the diagnostic acumen of primary care physicians.
Masked depression appears to be a common clinical phenomenon. Most depressions present with some somatic complaints in addition to affective and cognitive ones. About one half of all depressions seen by primary care physicians initially present predominantly or exclusively with somatic symptoms. Many of these depressions are not recognized or are misdiagnosed and mistreated. The possible reasons for this are discussed here. The phenomenon of somatization in depressions and other conditions is reviewed and the interface with other related clinical problems like hypochondriasis and conversion is delineated. It is hypothesized that the proportion of depressions that are masked is positively correlated to the patients' tendency to somatize and negatively correlated to the doctors' ability to recognize depressions that hide behind somatic complaints. Suggestions for the diagnosis and treatment of masked depressions are given.