You Can Be Depressed Without Being Sad

It is particularly important to identify depression without sadness (anhedonia) because recent research indicates that it may be anhedonia rather than sadness that correlates with poor physical health.
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Co-authored by Michael B. Friedman, L.M.S.W. and Kenneth G. Terkelsen, M.D.

Depression can be dangerous. Most people who take their own lives have a depressive disorder at the time (1). And people with both chronic physical illnesses such as heart disease or diabetes and a depressive disorder are at higher risk for disability and premature death than are people with chronic physical disorders who do not also have a depressive disorder (2) (3). That is why it is important to identify depressive disorders and to intervene in ways that effectively counter them.

But identifying depressive disorders is not as easy as it sounds, in part because people can have a depressive disorder without being sad (4).

This seems very strange because of the difference between "depression" as a psychiatric diagnosis and as an ordinary English word. Obviously, in ordinary English being "depressed" means being very sad. But as a psychiatric diagnosis, "depression" refers to a particular combination of symptoms. To have a diagnosable "major depressive disorder" (sometimes called "clinical depression"), you must have at least one of two particular symptoms -- called "cardinal" symptoms. Deep sadness ("depressed mood") is one of the two cardinal symptoms. The other is called "anhedonia" (Greek for "without pleasure"), which means not taking pleasure in pretty much anything, even in things that used to give you pleasure -- your work, your hobbies, your grandchildren, your friends, etc.

So if you have become bored with life, if you mostly sit around doing nothing unless you absolutely have to, if you find it difficult to rouse yourself enough to do even what you absolutely have to do -- you may have a depressive disorder.

Anhedonia, even in combination with profound sadness, is not enough for a diagnosis of major depressive disorder. There must be at least five symptoms in all. In addition to the two cardinal symptoms, these could include: sleep problems, having little energy, eating too much or too little, difficulty concentrating, moving or speaking noticeably slowly or being fidgety and restless, feeling that you are a failure, or thinking that you would be better off dead (5). People with major depressive disorder may also experience distressing ruminations, be irritable, or rely on drugs or alcohol to dull painful feelings (6).

Many people have depressive disorders without being aware that they do, and many of them muddle through life without getting help. Often their depression comes and goes. But it is important to remember that a depressive disorder can be dangerous and that you can get help.

First and foremost, if you are considering taking your own life, you should seek help. But even if you are "just" bored to death, you may have a major depressive disorder that could be dangerous -- especially if you have heart problems, high blood pressure, diabetes, or other chronic illnesses.

Where can you turn? Whether you are feeling suicidal or not, The National Suicide Prevention Lifeline -- 1- 800-273-TALK (8255) -- can connect you with the nearest mental health crisis information and referral service. Or you can talk to your family physician. Or you can seek help from a local mental health provider. Some people find that religious advisers and mutual aid groups can be helpful.

Physicians, too, need to take anhedonia seriously. Screening for depressive disorders is now recommended as a standard part of physical examinations, though unfortunately many physicians still do not do it (7). Some physicians ignore all but the most obvious psychiatric symptoms. Others ask questions such as "Have you been depressed recently?" Physicians should also be asking, "Have you lost interest in life?" because this question identifies depression without sadness.

It is particularly important to identify depression without sadness (anhedonia) because recent research indicates that it may be anhedonia rather than sadness that correlates with poor physical health (8). Why is not clear, but it may be that people who have lost interest in life just don't care enough or have the inner energy to do what is necessary to cope with or overcome chronic illness -- exercise, diet, taking medication, and so forth.

What can be done to overcome a depressive disorder? There are, of course, many medications that can be helpful, and physicians obviously rely heavily on them (9). However, there are other effective ways to counter depression. Psychotherapies, such as problem solving therapy, can be effective (10). Exercise also may be effective (11). Some recent research indicates that helping others (people and animals) tends to reduce depression (12) (13). But the major antidote to depression probably is being involved in activities and with people.

The problem, of course, is that some people with depressive disorders -- especially those who experience anhedonia -- just can't get themselves going. They are caught in a vicious cycle: The more isolated and inactive they are, the more depressed they are, and the more depressed they are, the more isolated and inactive they become. Formal interventions including outreach to encourage people to get off their couches, go for therapy, take their medications, or take a walk may well be essential for people caught in this vicious cycle (14). And sometimes, just getting a call from a friend saying, "Let's take a walk" is what gets a person with anhedonia going.

Need help? In the U.S., call 1-800-273-8255 for the National Suicide Prevention Lifeline.

Kenneth G. Terkelsen, M.D., is a general psychiatrist and Assistant Director for Behavioral Health Services of the Community Health Center of Cape Cod.

(1)American Association of Suicidology. "Some Facts About Depression and Suicide." 2010.

(2)For example, Freedland K. et al. "Impact of Depression on Prognosis in Heart Failure" in PubMedCentral, January 2012.

(3)Ciechanowski, P. et al. "Depression and Depression ... " in Archives of Internal Medicine, November 2000.

(4)Gallo, J. et al. "Depression Without Sadness..." in Journal of The American Geriatric Society, May 1997.

(5)Drawn from a standardized screening instrument for depression, known as the PHQ-9

(6)Anonymous. "DSM-IV Criteria for Diagnosing Depression" in Depression Today.

(7)Maurer, D. "Screening for Depression" in American Family Physician, January 15, 2012.

(8)Davidson, K. et al. "Association of Anhedonia With Major Adverse Cardiac Events ..." in Archives of General Psychiatry, May 2010.

(9)National Institute of Mental Health. "How Depression Is Diagnosed and Treated".

(10) National Institute of Mental Health. "How Depression Is Diagnosed and Treated".

(11) Mead, G., et al. "Exercise for Depression" in The Cochrane Library January 2010.

(12) Layous, K. et al. "Delivering Happiness: Translating Positive Psychology Intervention Research..." in The Journal of Alternative and Complementary Medicine, 2011.

(13) Thompson, D. "With Depression Helping Others May In Turn Help You" in Health Day, January 2, 2012.

(14) Katon, W. et al. "Collaborative Care for Patients With Depression and Chronic Illness" in New England Journal of Medicine, December 30, 2010.

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