The American Psychiatric Association (APA) outlines the formal diagnostic criteria for major depressive disorder in its current diagnostic manual the Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition (DSM-5). In order for an individual to be diagnosed with major depressive disorder, they must exhibit at least five of nine potential diagnostic symptoms (listed in the DSM-5) over a two-week period (the same symptoms must be present in the two-week period) and one of the symptoms must include having a depressed mood (e.g., sadness) or a significant inability to feel pleasure (or a loss of pleasure that is demonstrated by a significant loss of interest in things that were normally interesting to the person). The diagnosis of major depressive disorder cannot be made by any medical test, such as a blood test or scan. Instead, the person must exhibit behavioral symptoms like sadness, fatigue, energy loss, sleep difficulties, etc.
Depression with Atypical Features
The APA also lists several different types of presentations of depression. One of these particular types of presentations is depression with atypical features. Depression with atypical features would be depression that presents as somewhat different than what the majority of individuals diagnosed with major depressive disorder present with. For example, the diagnostic criteria for major depressive disorder with atypical features would first have to meet the diagnostic criteria for major depressive disorder; within that context, the individual might also display:
- A reactivity of mood where the individual may at times not be sad and mood may become brighter when certain events occur.
- Two or more of the following symptoms:
- A significant gain in weight or appetite increase (typically, weight loss or a decrease in appetite).
- Significant sleeping (hypersomnia; typically, insomnia).
- A phenomenon known as leaden paralysis, where the individual has heavy feelings in their legs or arms.
- Sensitivity to perceived rejection from others that causes significant impairment in relationships or work.
Individuals with atypical depression cannot meet the criteria for other types of depression, such as catatonic depression (being frozen in particular poses) or melancholic depression that typically presents with features of guilt, loss of pleasure, and a lack of reactivity to pleasurable stimuli.
In concealed depression or masked depression, individuals have an atypical form of depression where they do not typically report that they feel sad most of the time, but are masking their symptoms. In some instances, they may be attempting to deal with their symptoms in a behavioral manner by downplaying their distress and overtly appearing to not be depressed. Other symptoms may be present. Many of these individuals often complain of physical symptoms (somatic symptoms) that can include headaches, backaches, abdominal pains, chest pains, tingling, etc. In addition, concealed depression is believed by some to take the form of compulsive-type behaviors, such as becoming a workaholic, compulsive gambling, and even substance abuse in place of presenting with traditional sadness or loss of interest in everyday activities.
How Common Is Concealed Depression?
According to references to concealed depression, which were far more prominent prior to the 1990s than they are currently, this presentation is relatively common. It may be as frequent as depression that is overtly detected and occurs across all ages but may be most common after middle age.
In some cultures, the practice of hiding one’s feelings is a culturally accepted attitude, and displaying feelings, particularly issues with sadness or perceived inadequacy that is not an attempt to be humble but an attempt to elicit help, is often frowned upon and a sort of cultural taboo. For example, in some Asian cultures, the reported prevalence of clinical depression could be significantly higher than the reported prevalence of depression in people with cultural backgrounds where it is acceptable to overtly express and display these types of symptoms and behaviors. Additionally, in other cultures, males may be more likely to attempt to minimize distress associated with depression or anxiety due to cultural notions of masculinity and femininity. Children in all cultures often have difficulty expressing their feelings, and this may fuel the notion that they are concealing issues with their mood.
If the prevalence of major depressive disorder should be the baseline that is used to estimate the prevalence of concealed depression, then the best estimates of prevalence come from the APA. They report that the overall 12-month prevalence of major depressive disorder is approximately 7 percent; the 12-month prevalence is the percentage of individuals who actually have the diagnosis of the disorder within any 12-month period. However, this figure can change depending on numerous demographic factors. For example, females have rates of depression that are 1.5-3 times higher than males, and the prevalence of depression is three times higher in individuals between the ages of 18 and 29 compared to those over the age of 60. These figures are based on estimates of the disorder that come from individuals who can be readily assessed for depression. Obviously, it would be very difficult to accurately estimate the prevalence of so-called concealed depression if individuals do not overtly admit their symptoms.
Signs of Concealed Depression
Most symptoms of concealed depression or signs of hidden depression can be found on popular lay websites. There are no formal diagnostic criteria for concealed depression, unless one refers to the diagnostic criteria for major depressive disorder by APA; concealed depression is considered to be a form of depression with atypical features. Nonetheless, some sources suggest that signs of concealed depression include:
- Unusual eating, drinking, or sleeping patterns (These are actual signs of depression, such that individuals with major depressive disorder often have a lack of appetite, have difficulty with sleep, and may turn to drugs or alcohol.)
- Tendency to force feelings of happiness and try to excuse away issues.
- Introspection, as individuals may begin to ponder big questions, such as the meaning of life, what happens after death, etc.
- Intense feelings.
- Putting out a cry for help but attempting to excuse or cover it up.
Unfortunately, the above tendencies or symptoms are not diagnostic symptoms of anything. People often have periods of intense feelings, being less optimistic, making excuses, becoming introspective about life, etc. These so-called signs are not specific to people attempting to mask or conceal a psychological disorder, and there is no research evidence that supports their diagnostic utility.
Assessing Concealed Depression
Numerous assessment techniques for identifying and accurately classifying any particular type of mental health disorder exist. Interestingly, there are several articles written on assessing “concealed depression” that are not authored by mental health professionals, which obviously calls into question their usefulness and validity.
Assessing depression in an individual who may not be forthright regarding their symptoms can be challenging. Nonetheless, a thorough assessment performed by professional and licensed mental health clinicians will often uncover these issues. According to professional sources like the book Evidence-Based Practice and Primary Care, these include:
- A clinical interview with the person.
- Numerous psychometric instruments, such as questionnaires, surveys, etc., to ascertain the individual’s thoughts, beliefs, attitudes, feelings, etc.
- An interview with the person’s relatives or close friends.
- Behavioral observations of the person.
As it turns out, experienced, professional mental health clinicians are readily able to identify depressive symptoms in individuals who may not overtly express them to the untrained eye.
Clinicians who use a combination of the above techniques, particularly the use of a thorough clinical interview and psychometric instruments, will develop solid hypotheses regarding the individual’s behavior and are able to follow up on those.
Despite what is often printed in the popular media, there are no medical tests that can reliably diagnose depression or the majority of mental health issues that are listed in the DSM-5.
Thus, clinicians are trained in methods of assessment and diagnosis to be able to thoroughly understand the issues driving an individual’s behavior. This is not meant to imply that these assessments are always wholly correct in their determination; in fact, like any type of diagnostic procedure (including medical diagnostic procedures), errors can be made. But, for the most part, the diagnosis of any presentation of major depression is reliable; if errors are made in the initial diagnosis, the use of further observation, treatment, and assessment often helps to clarify the issue.
Considerations in the diagnosis of major depressive disorder include:
- The age of the individual: Often, the symptoms of depression can vary depending on an individual’s age. Younger individuals (adolescents and children) and elderly individuals often present with different symptom profiles than young adults and middle-aged adults.
- Ruling out any co-occurring medical conditions, such as a thyroid problem or cardiovascular issue: Numerous medical conditions can affect an individual’s mood. If these are treated properly, the issue with the individual’s mood often dissipates significantly.
- The cultural background of the individual: As mentioned above, cultural norms regarding behavior often interact with the presentation of issues with mood or other mental health issues.
- Other mood issues: Because nearly every type of psychiatric/psychological disorder listed in the DSM-5 has some level of depressed mood or even anxiety associated with it, it is important to rule out other contributions to the person’s mood in order to understand the individual’s primary problem.
- Personal variations: Thoroughly understanding of the individual’s motivations, goals, belief system, and self-view is crucial in identifying the source of issues with mood. Ruling out issues, such as bereavement, normal variations in mood, standard variation based on different personality styles, other potential mental health issues, etc., needs to be done before any diagnosis is made.
Individuals who may not overtly appear distressed or functionally impaired can often present a diagnostic challenge; however, this issue is not a rare one by any means. Professionally trained and experienced clinicians encounter the issue quite often with all forms of psychopathology, including anxiety issues, trauma and stressor-related issues, personality disorders, psychotic disorders, etc. Individuals who have depressive disorders are not the only group of individuals who attempt to conceal their issues or downplay them in an attempt to adapt to them.
Is Concealed Depression a Real Diagnosis?
Essentially, the notion of concealed depression or hidden depression is an older notion that still receives a moderate level of attention from numerous lay sources, such as The Huffington Post and others; however, it does not represent a formal diagnostic category. Again, an attempt by an individual to downplay their level of distress is not limited to individuals with depressive disorders.
According to the DSM-5 and numerous other clinical sources, other than a diagnosis of depression with atypical features, the notion of “concealed depression” is not considered a standalone diagnostic entity. It is well accepted that some individuals may exaggerate psychological or physical symptoms in order to get some form of secondary gain or as a cry for help (often referred to as malingering or “faking bad”), and some individuals may attempt to conceal clinical issues (often referred to in psychological circles as “faking good”) as a form of adaptive response. These individuals who are “faking good” are often seen as using defensiveness, a minimization of symptoms, concealment, a style of socially desirable responding, underreporting, etc. Thus, while it is generally accepted that there is some proportion of individuals who qualify for a diagnosis of clinical depression that may not overtly express issues with depression, there is no formal diagnostic term or label of “concealed depression,” “hidden depression,” etc.
Individuals who underreport the severity of their symptoms are often trying to cope with or adapt to their distress, and trained clinicians understand this, routinely deal with this issue, and have approaches and techniques to identify and assist in the treatment of these individuals. This is not an uncommon occurrence. For instance, it is well accepted that many individuals with active substance use disorders are very insistent that their behavior is not dysfunctional, even when it is quite obvious to others that they have a serious substance abuse issue; however, there is no such thing as a diagnosis of a “concealed substance use disorder” or a “concealed addiction.”
Individuals who attempt to downplay their symptomatology will often require a slightly different treatment approach than those who are more open regarding their feelings; however, treatment for individuals with concealed depression would typically follow the standard protocol for treating depression.
Treatment for Concealed Depression
The treatment protocol for major depressive disorder will typically include several of the following:
- Psychoeducation: While the use of instruction and education alone is not a form of treatment, it can be useful for individuals who minimize their distress. Helping the person understand the relationship between their feelings and behavior as well as helping them develop a realistic self-concept can prepare them for treatment and result in a more successful treatment outcome.
- Medications: Individuals with any form of major depressive disorder are often treated with medications. Several classes of antidepressant medications exist, and within each class of antidepressant, there are numerous medications to choose from. All of these medications have slightly different mechanisms of action that make them useful in treating various presentations of depression. While antidepressants are commonly prescribed by general practitioners and other physicians, it is best to have them prescribed by a psychiatrist who is specifically trained in understanding the differences in these medications and how they affect individuals who use them.
- Psychotherapy: Psychotherapy for depression has an extremely large body of empirical literature to support its effectiveness. Typically, the preferred form of psychotherapy for the treatment of depression is some form of Cognitive Behavioral Therapy that addresses the individual’s belief system, attitudes, and behaviors, and attempts to help the individual alter these to more functional and adaptive responses. Nonetheless, other forms of psychotherapy can also be useful in the treatment of depression.
- Medication and psychotherapy in conjunction: The literature generally supports the notion that a combination of medication and psychotherapy is a successful approach to treating depression and may often be more efficacious than the use of medication or psychotherapy alone.
- Other alternative interventions: Other interventions can also be useful, including forms of complementary and alternative therapies like yoga, tai chi, music therapy, adventure or wilderness therapy, etc. The implementation of an exercise program may have very positive benefits for individuals with depression; however, individuals should always have a full physical examination before beginning any exercise program.
- Lifestyle changes and support: Many individuals with depressive disorders will benefit significantly from lifestyle changes (e.g., quitting use of alcohol or drugs, or switching jobs) and social support from others. Typically, therapists assess the individual’s social situation fully and discuss the negative roles that certain lifestyle situations or practices have on their mood; however, making drastic lifestyle changes may have the opposite effect. For the most part, individuals who change jobs, get out of relationships, change their college major, etc., should thoroughly review the implications of any potential pending changes and discuss these with their therapist and others before making them. Making major lifestyle changes while an individual is emotionally distraught can often result in the situation worsening if the individual does not receive support and assistance from others regarding understanding the implications of such changes.
- So-called “concealed depression” where individuals may attempt to downplay their distress, does often represent specific challenges for treatment providers and may require specific alterations in the treatment approach that are tailored to the needs of the individual; however, it is well documented in clinical circles that treatment approaches for mental health issues should always follow an overall blueprint that has empirical research evidence to support it, and the blueprint should be altered to fit the individual needs of the person being treated.
- The overall approach to recognizing and treating issues that occur in individuals who tend to downplay or minimize their symptoms remains similar to the approaches for individuals who are more forthright regarding their stress, but may require slight alterations in the normal assessment and treatment protocols to suit the particular case. This may often involve the use of more instruction and education to help the individual understand how their mood affects their behavior as well as to develop a more realistic self-concept.