Depression Without Depressed Mood?

When we use the term “Depression” in the casual sense, we mean sad or down in the dumps. When used as a medical term, “Depression” refers to a whole group of symptoms that together form its actual “textbook” definition. This constellation of symptoms, which are spelled out in DSM — the Diagnostic and Statistical Manual of Mental Disorders — does include depressed mood, but only as one of nine symptoms of Depression. In fact, depressed mood itself, believe it or not, is not necessary for the diagnosis of Depression.

In this way, the term Depression is merely shorthand — a convenient way for health care professionals to communicate with each other about this condition rather than listing all of the symptoms every time. This is not to say that a sad or depressed mood is not a typical or important criterion, it is simply neither necessary nor sufficient to make the diagnosis. According to DSM, to meet the criteria for Major Depression, an individual may have either a depressed mood or “anhedonia” in addition to several other symptoms of depression. Anhedonia is a lack of interest in, or enjoyment of, things in a person’s life. Anhedonia also captures the sense of pessimism, apathy, or glass-half-full thinking that patients with depression may experience.

The other symptoms of Depression according to DSM are as follows: decreased energy; change in sleep patterns (either insomnia or feeling too sleepy all the time); change in appetite; decreased self- attitude (includes feeling down about one’s self, lack of self-esteem, lack of self-confidence, self-blame, or prominent feelings of guilt); so-called “psychomotor retardation,” which patients experience as feeling run down, that physically things seem effortful; poor concentration, which impairs problem-solving and can cause a person to experience their thinking as sluggish, which together with psychomotor retardation and low energy can make it hard for people with depression to get things done; a feeling that life isn’t worth living or actual suicidal ideation; and decreased sex drive. Note that it is not necessary to have all of the preceding symptoms to meet the criteria for Depression. Seeing the list of these symptoms, it makes more sense than a depressed mood may not be the most bothersome feature of Depression.

We can also see from the criteria for depression how, similar to other medical conditions, patients may feel both mentally and physically unwell. To further underscore that depressed mood may not be the most prominent part of the syndrome, for children and adolescents irritability is also considered a substitute core symptom instead of depressed mood or anhedonia. This explicitly acknowledges that this age group may have difficulty interpreting and expressing how they are feeling, and irritability may be the external manifestation. A similar phenomenon can be seen in adults when everyone around the person sees they are depressed, but they don’t recognize it themselves (for which there can be a number of explanations). Although an imperfect description of the condition, we can see the convenience of using the term Depression to refer to a whole constellation of symptoms, rather than iterating every time that the person has lack of energy, can’t get negative thoughts out of their head, are feeling run down, etc… The drawback of using Depression as a catch-all term is that people may not recognize the other symptoms as being part of a well-characterized condition that would benefit from clinical attention.

Best Regards, Dr. Ranen (Psychiatrist Baltimore, Baltimore County, Owings Mills)