Smiling Depression

Smiling Depression, are you smiling on the outside but struggling on the inside?

by Dr. William Anixter, MD, Psychiatrist at CooperRiis

Originally published January 4, 2023

“People say I’m the life of the party ’cause I tell a joke or two. Although I might be laughing loud and hearty, deep inside I’m blue.”  

-Smokey Robinson

What is Smiling Depression?

Smiling depression is not a clinical diagnosis, but it is a common presentation of MDD, or Major Depressive Disorder. In current mental health parlance, smiling depression refers to someone who is struggling with the illness of depression while presenting a smiling face to the world. Specifically, depressive symptoms and a happy outer appearance co-occur in smiling depression, also known as masking.

It can be as serious and at times more dangerous than depression without a smiling presentation. There are several reasons for this. First, maintaining a happy face for the world while feeling despair and hopelessness inside takes a great deal of psychic effort and energy. Depression is an illness that does not take place over a few days, so hiding it week after week or month after month is exhausting.

It also interferes with a person’s ability to be honest with friends and family about how they feel, further contributing to isolation and loneliness. At times, those involved in the person’s life might be fooled and may not reach out to help as they might otherwise.

Smiling Depression Symptoms

Smiling depression symptoms obviously overlap a good deal with the other symptoms of depression. But we have to look closer to see them when a person is masking at work, at school, or in social situations. We may see this person functioning fairly well, appearing as though nothing is wrong, and yes, even smiling and making jokes. Outward signs to look for may include:

• Social isolation that seems unusual for the individual: not responding to texts or returning calls, last-minute cancellations, liking social media posts but not commenting.
• Increased caffeine consumption.
• Changes in how they eat, such as not eating at lunchtime or no longer eating a variety of foods.
• Increased self-deprecating humor.
• Irritability, snapping at others, or seeming resentful (perhaps in a “joking” way).
• Poor concentration or increased errors and overlooked details in work.
• Unexplained physical problems, like pain, headaches, or exhaustion.
• Decline in personal grooming or neatness of home/office/car.
• Loss of interest in hobbies, projects, or loved ones.
• Uptick in substance or process use: alcohol, drugs, social media, video games, gambling.

Any of these signs alone may mean nothing, but seeing a few of them together or in a short time should register as a red flag. And we’re looking for these behaviors to show up anew. If someone has eaten the same food for lunch every day for five years or always been introverted, these shouldn’t necessarily be taken as signs of hidden depression.

Why Depression and Smiling?

There are a variety of reasons someone might be experiencing depression and smiling through it. Some people have been taught to hide their emotions through cultural norms of family ways of being. Cognitions or assumptions leading a person to mask depression with a happy demeanor might include:

• Men / adults / parents aren’t supposed to cry.
• Appearing depressed will burden the people around me.
• It may cause personal or professional consequences.
• It’s not safe to show my feelings because others might ridicule or reject me.
• People count on me to cheer them up.
• Depression is a sign of weakness or something to be ashamed of.
• Tough it out, and things will get better.
• If my family knows I’m depressed, they might have me locked up.

These motivations can be either conscious or unconscious, something a person is aware of and does with intention, or something buried in past experiences. But they’re all rooted in some kind of denial, which can tear a person apart over time.

How to Help Someone with Smiling Depression

Depression is a mood disorder characterized by neurobiological differences, which means it doesn’t go away. It certainly can go into remission for many years, but most people need ongoing support to experience lasting relief like that. For this reason and others, someone with the condition of depression will ideally already have a therapist and access to other support resources.

However, this won’t be the case if someone is experiencing their first depressive episode. It’s also less likely if they’re prone to denial of symptoms, as one with smiling depression may be. In these instances, the need for help can be harder to flag. When the misalignment between presentation and internal experience have worn a person out or damaged important relationships, that’s one sign it is time.

This is also where friends and family should step in to help if they haven’t already. Trusted loved ones, and even acquaintances or colleagues, may be able to nudge someone towards seeking therapy. And here are some scenario-specific suggestions on how to help someone with smiling depression:There are also several highly effective meditations which can help treat the low mood, improve sleep patterns and control anxiety.

• Your normally kind friend snaps at you. Instead of exiting the situation and avoiding them, ask if they’re doing okay.
• A friend or colleague is withdrawing. Try to set a regular “thing,” but keep it low-pressure. A 10-minute walk after lunchtime at work, coffee together or a casual Zoom call once a week, a 30-minute chat on their porch every Sunday at noon.
• A family member has ditched their hobbies and is spending a lot of time at home alone, doing nothing it seems. Ask them to help with easy tasks that you really need help with, like making decorations for a birthday party, picking up your child at school, repairing something that’s within their skillset.
• A friend keeps canceling plans. Call them the day before or the morning of to confirm. Let them know how much you’re looking forward to it.
• You notice that every time you call your sister lately, she’s eating avocado toast, or fixing avocado toast, or just had avocado toast for dinner (and had it for breakfast too). If she wants company, go over and cook at her house once a week. If not, drop off snacks or meals for her every few days. (If she isn’t nearby, send it via DoorDash.)
• A colleague’s self-deprecating humor is on an upswing, and you’re worried they’re feeling poorly about themselves. If you’re close with them, say you’ve noticed it and ask if they want to talk about what’s behind it. If you’re not close, make a point of giving honest, in-context positive feedback: “I really appreciate the way you seek clarity on things. I think it helps the rest of us avoid a lot of pitfalls.”

A note about suicidality: If someone seems “fine,” but you notice sudden calm after a rough stretch, goodbye-style messages, tidy distancing from ongoing plans or obligations, or out-of-character risk-taking, check in privately and ask in plain language: “Have you been dealing with any depression or apathy lately?” “What about suicide? I know some people think about that in an idle way, but have you been making any plans or anything?” This may be a good time to bring in trusted others (big emphasis on trusted), if even just for company or distraction.

Professional Help for Depression

Mental health professionals have a number of approaches that can help. Forming a trusting connection with someone like a therapist can be a big first step in breaking out of the prison of isolation that depression and masking can create. Commonly used techniques include:

• Cognitive behavioral therapy (CBT): Identify and modify distorted thought patterns that perpetuate negative feelings.
• Interpersonal psychotherapy (IPT): Target relationship stress, role changes, grief, and isolation that fuel depression.
• Behavioral activation (BA): Systematically schedule small, rewarding activities to restart motivation and mood.
• Acceptance and commitment therapy (ACT): Build acceptance skills and take values-based actions, even with difficult feelings.
• Mindfulness-based cognitive therapy (MBCT): Mindfulness and light CBT to reduce rumination and prevent relapse (especially recurrent MDD).

There are also several highly effective medications; and professional therapists also often help their clients incorporate incremental lifestyle changes to stabilize mood over the long term. At CooperRiis, we offer residential treatment for depression that incorporates all of these things and has been life-changing for many people.

Closing Thoughts

We can make a big difference in the lives of others through attention, attunement, and small actions. It’s easy for those closest to a person in active depression to feel hopeless too, especially if that person is masking with smiles and a cheerful presentation. But, every little point of contact matters, and you can help.

What if it’s you? What if you’re the person feeling depressed and smiling to hide it? Try your best to believe these absolutely true things:

• Your friends and family want to help.
• You can stop masking without being a big messy mess.
• You can open up to receive [deserved!] support without everyone knowing your deep, dark secrets.
• Even the very darkest thoughts come from depression; they don’t make you a bad person.

You still may not believe those things, but they really are true. So, if you find yourself feeling like Tony Soprano, having to be “the sad clown, laughing on the outside, crying on the inside,” please consider reaching out to a mental health professional, a trusted teacher or mentor, or a supportive friend or family member and let them know you need help. Depression is treatable, profound relief is possible, and you do not need to go it alone.