"Smiling depression" (an emerging threat): Let's Talk

Abstract

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.

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CME
“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
Abstract
Introduction
Methodology
Results
Conclusion
References
Citation
Tables / Figures
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: docsudip84@gmail.com
Citation
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.
Abstract
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.
Keywords
Depression; mental health; pain
Introduction
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
pleasure.(4)

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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)
Diagnosis
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
suicide.(5,10,11)
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-
reporting
● Psychologic features, personality profile, and
family history related to neuropsychiatric
problems
● 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 (22–78 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
depression.(8)
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

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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
herself.
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.

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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.
References
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8a2.htm
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Severity: Implications for Clinical Practice. Front Psychiatry
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Tables
TABLE 1 DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS -V (DSM-V)
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.