Masked depression appears to be a common clinical phenomenon.
Depression is a global issue and it’s gradually making its way to be the most fatal disorder of the century. According to World Health Organisation, approximately 300 million people of all ages suffering from depression, making it the most common mental health issue.
Close to about 0.8 million people die due to suicide, which is mostly instigated by depressive disorder every year, ranking it the leading cause of death in people aged 15-29-years.
Even after the increasing awareness around mental health issues, where exactly are we going wrong?
How is masked depression different from Depression?
The terminology “masked depression” was largely used in the 1970s and 1980s to describe patients who complained of somatic symptoms, without any identifiable organic disorder. (1)
However, Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM 5) do not categorize ‘masked depression’ as a mental disorder.(2) The International Classification of Diseases 10th Revision (ICD-10) only briefly mentions “single episodes of masked depression not otherwise specified” under the category of “other depressive episodes.”(3)
Several terms like atypical depression, depression equivalent, a vegetative equivalent, a depression without a depression, and a hidden depression can be used to describe masked depression. Masked depression is critical for practitioners to identify because of the predominance of somatic symptoms over cognitive and affective symptoms.
When a person is suffering from major depressive disorder, he/she has affective symptoms like feelings of hopelessness, worthlessness, helplessness, low mood, anhedonia, lack of motivation; cognitive symptoms like difficulty concentrating, slow processing of information, difficulty in decision making, suicidal ideation. But these symptoms are not visible in masked depression as concretely as in MDD.
Here are some identifiers and symptoms of masked depression which might mimic the symptoms of Major Depressive Disorder:
- Lack of motivation and interest in previously found pleasurable activities
- Anger and irritability
- Difficulty concentrating, making major decisions and remembering things
- Extreme fatigue (not due to any identified organic disorder)
- Low mood (which temporarily lifts in response to positive events and experiences)
- Extreme negative response to perceived or real criticism or rejection
Alongside the aforementioned symptoms, a person suffering from masked depression also suffers from somatic symptoms such as (4):
- Musculoskeletal aches
- Changes in appetite
- Changes in libido
- Disturbances in sleep pattern – mostly a pattern of increased sleep is seen in masked depression
- Dyspnea – shortness of breath, feelings of tightness in the chest
- Disturbances in gastrointestinal tracts
- Lack of energy
- Weight gain
- A heavy or laden feeling in arms and legs.
People with masked depression, themselves find it difficult to identify what is going on below the surface. This leads to the close people of the affected person to also stay in oblivion about the disorder, further delaying the treatment procedure.
Masked depression might be:
- hidden, for instance, “I am too busy with work and have no time to socialize.” or in contrast “I am a social butterfly. I hate being left alone.”,
- it can be ignored, for instance, “I am just a bit stressed. Nothing else.” or
- it can be displaced with anger like “There is nothing wrong with me. Just stay away from nagging me.”
Why is masked depression difficult to identify?
What makes depression a tricky disorder to understand is it’s presentation. Depression manifests itself in various different forms. No two people have the same symptoms when it comes to depression.
Some people with depression might have symptoms which are not typically found in cases of depression – like the person who has depression might somehow be pulling of work but feeling sluggish and fatigued, they may seem overtly optimistic and might also have a self defensive judgement of being fine and content with life, feel a general lack of enthusiasm towards life etc.
The reason why masked depression often remains misdiagnosed is due to the predominance of somatic symptoms. This is further complicated by lack of awareness among mental health practitioners.