file4221287396229What do a 45-year-old professor, several well-educated parents, a retired psychotherapist, a concerned husband, and a college student all have in common? These are people suffering–or intimately connected to someone suffering–from clinical depression who didn’t know it.

How, in this day and age, with so much information available, is it possible that depression can still go undiagnosed and therefore untreated? Perhaps this is part of the reason why the blog “Depression Part Two” on Hyperbole and a Half  just went viral (besides how extraordinarily creative it is). Here are some reasons why smart people can miss the signs of depression:

1. Depression can creep up on you.

Not all depression is so severe that you can’t stop crying or get out of bed. For many people, the feelings of sadness manifest as a growing disinterest in life’s activities. What used to be fun or interesting seems unimportant or shallow. You don’t feel like going to your friend’s birthday party so you make up an excuse. You feel bored by the books or TV shows that used to appeal to you. You don’t notice how, little by little, you are pulling back from others, spending more time alone, locked in your room.

2. Depression seems to be a logical response to life’s challenges.

Since depression often worsens or can be triggered by loss or stress, you figure that you are responding appropriately to what is indeed a painful time in your life. You may have broken up with a boyfriend, had difficulties at work, done poorly on a school assignment, or moved away from a supportive environment. When you don’t snap out of it, even when your life circumstances appear to get better, you don’t realize that your negative mood state has persisted for months or even years. file000349823764

3. Some depression manifests as extraordinary irritability rather than sadness.

One of the most commonly misunderstood or overlooked manifestations of depression is hypersensitivity or irritability. People around you tell you that you are constantly cranky. You seem annoyed (and feel annoyed) at every little thing. People or activities that you didn’t like before become intolerable. One of my clients, Sally, upset her husband and kids because she yelled at the TV announcers and seemed critical and judgmental about everything. Only when I inquired about whether Sally might be depressed, did she realize that she was sleeping an inordinate amount of time and no longer had any appetite. She never felt sad, just incessantly irritable.

4. Some depression manifests as extreme anxiety.

Many people do not realize that anxiety is a frequent companion of depression. Mark, a local college student, came to see me because of paralyzing test anxiety and social phobia. Since he did not feel sad and never cried, Mark attributed all of his problems to his fears. Only after a thorough assessment that revealed his gradual weight gain since high school, his difficulty with sleeping, his growing disinterest in sports (which had been his passion), did Mark realize that his anxiety was one of many symptoms of his depression.

5. If you’ve been depressed your whole life, it just seems normal.

I worked with Randall, a 54-year-old math professor, who never said a word about being depressed. He had even had bouts of suicidal thoughts on and off since he was a teenager. Randall’s mother was chronically unhappy, and his father was an alcoholic. Surrounded by a family of unhappy people, this client thought of his mood state as normal. It never occurred to him that he might learn to treat himself more generously. To be happy was unthinkable in Randall’s world.

file00018721129056. You have been raised to be stoic in the face of any form of pain.

Justina came into therapy because her child was having problems adjusting to school. She insisted initially that everything was fine in her life. It was only when her son told her that he was afraid to go to school because he thought his mom might hurt herself that Justina began to talk about how difficult it was to get out of bed every morning. As we talked further, she described her upbringing in a highly religious family where she was not allowed to complain. Her parents taught her to be grateful for her privileged life in a world where others suffered from poverty and religious persecution. Justina’s shame about what she saw as her personal weakness had kept her from talking about how badly she felt.

7. You feel hopeless, believing nothing will change how you feel.

Another group of people just soldier on, convinced that there is nothing anyone could do to help. Since depression causes people to withdraw from life, to stop reaching out to others, and to be immobilized by insecurity and anxiety, the idea that their misery is unchangeable becomes a self-fulfilling prophecy. The very things that loved ones do to try to help–telling the depressed person to exercise, go out more, drink less, and look at the bright side–are the very things that the depression makes impossible.

Do any of these sound familiar? If so, you are not alone. There are numerous resources both here at PsychCentral and elsewhere. And thank you to blogger Allie Brosh for her willingness, not only to share her own struggles with depression, but to do so with both humor and hyperbole. Hope comes in many forms.