Becky took a deep breath, cemented a smile on her face, and stepped out of her car, swooping down to wrap her niece and nephew in a giant hug.
The 37-year old Chicago teacher pushed away the thoughts that had been playing on a loop in her mind during the drive to her family vacation: What if I crash the car? Now I’ll never have time to prep my classroom for the school year. I shouldn’t have agreed to come. But it had taken Becky’s mom weeks of cajoling to convince her to join the family at a Michigan lake house, and Becky didn’t want to let her down. For the next three days, she played with her sister’s kids, posed for pictures, and went for boat rides—all while hiding her growing sadness and her panic about the drive home.
On the last day, she snapped one final happy photo from the boat and posted it to Facebook with the caption “Last boat ride on Magician Lake this summer!” But inside, her turmoil was building, threatening to crack her upbeat exterior.
The minute she stepped off the boat, she practically leaped into her car. Her only good-bye was a curt “I have to go right now.” When Becky got home, she fell into bed, sobbing. “Once again, I couldn’t enjoy myself, even though I was surrounded by my favorite people.”
For millions of women, this dichotomy between inner anguish and outer cheerfulness is all too familiar. Experts call it “smiling depression,” in which individuals put on a false front to hide symptoms. Surprisingly, they say that it—as well as its sibling form of anxiety—is far more common than more severe forms of the illness.
These women aren’t the stereotype, shuffling around under gloomy gray clouds or too anxious to leave their homes. According to a survey of more than 2,000 women conducted by Women’s Health and the National Alliance on Mental Illness (NAMI), 89 percent of respondents with depression or anxiety (self-described and officially diagnosed) said they can keep their struggles under wraps while performing day-to-day activities like going to work and hanging out with friends.
At first glance, manageable symptoms may seem preferable to being unable to get out of bed for three days straight—but that’s exactly what makes smiling depression so insidious, and so dangerous. The ability to look and act put-together renders the illness invisible to loved ones who might otherwise reach out with support. And without the more obvious markers of depression, many women self-stigmatize, believing that their unhappiness isn’t “bad enough” to talk about or that they should be able to handle it alone, says psychiatrist Ken Duckworth, M.D., medical director at NAMI.
For months, even years, women can feel as if they’re just going through the motions of life. It often takes experiencing a major hiccup—a period when their symptoms (health crushers like insomnia, loss of appetite, and extreme stress) worsen to the point where they’re nearly unbearable—for a woman with smiling depression to reveal her reality. Nearly a quarter of our survey respondents who had depression or anxiety waited more than five years to ask for help; over 35 percent have never sought treatment.
Without support from loved ones or professionals, people with smiling depression can suffer just as seriously from their condition as those with more acute forms of the illness. Left untreated, it can eat away at a woman’s mental and physical health and lead her to self-medicate with drugs or alcohol—or even to try to take her own life, which can shock people around her.
MASTERS OF DECEPTION
The ballbuster with the corner office. The president of the PTA. The Lululemon-clad yogi in your hatha class with the flawless headstand. Ambitious, high-achieving types are actually most at risk for smiling depression, since the same perfectionist tendencies that help them crush their goals also fuel their distress. When unhappy or anxious, perfectionists tend to try even harder and raise their expectations higher, only to continue to feel as if they’re not good enough, says Dean Parker, Ph.D., a clinical psychologist in New York City. “It’s a vicious cycle of negativity, which only adds to their depression.”
It’s these successful women who are especially adept at hiding their problems so they can protect the image that they’re fully capable, says Carol Landau, Ph.D., a clinical professor of psychology at Brown University. And their perfectionism feeds the internal stigma that keeps them from seeking help. “Divulging their struggles to friends is akin to admitting they’re not perfect, and seeing a therapist makes them feel that they can’t hack it,” says New York City psychiatrist Catherine Birndorf, M.D.
In our WH-NAMI survey, 62 percent of women with smiling depression said they masked their symptoms because “it’s easier to smile than to explain how I feel,” and another 53 percent told us: “I don’t want to appear weak or out of control.” They keep their illness in the shadows with tactics like withdrawing from social plans, not giving an honest answer when someone asks how they’re feeling, and posting social media photos and captions that don’t reflect the pain they feel inside.
Let’s pause on that last reason—because we’re all guilty of sharing snaps that depict us in our best moments. But it feeds the facade. Studies show higher social media usage is associated with greater levels of depression, possibly because everyone’s carefully curated “winning at life” images provide a perfect ruler by which to judge how we (don’t) measure up.
TRAPPED BY THEIR SECRET
As recently as a decade ago, smiling depression wasn’t fully recognized by the mental health community, largely because mental illness was so taboo that only people with the most intense symptoms sought treatment, says Landau. It wasn’t until the stigma softened and people with milder issues looked for help that professionals realized just how common smiling depression is. Some refer to it as “high-functioning depression,” but that’s really a misnomer, says Duckworth. Depression always has an impact on a person’s ability to function, even if it’s not obvious, he explains. “A woman might be able to go to work but be unable to concentrate when she’s there. She may rally herself to go out with friends but feel flat the entire evening.”
That pattern of keeping up appearances yet white-knuckling through (or denying the severity of symptoms) is often unsustainable. People with depression or anxiety can have difficulty sleeping, constant headaches, digestive problems, irritability, and swings in appetite, which only bring them down more.
Worse, if and when a woman does divulge what’s really going on, others may brush off her struggles because things seem to be going so well for her. This practically forces women to get worse before they can start getting better. Marilyn, a 48-year-old Jackson, Mississippi, state government worker, covered up her depression and anxiety for years. To friends, she was the cheerful volunteer at church. Then her home was robbed. Plagued by worries that she’d never be safe again, Marilyn mustered the courage to tell a friend, only to have her fears minimized. “She told me if I just prayed, I’d feel better.” When her depression intensified again several years later after the death of her parents, Marilyn kept it to herself. “I didn’t want to be shut down with a cookie-cutter answer again,” she says. She tried to cope alone for months, stress-eating to ease her sadness, before finally confiding in her pastor, who urged her to see a therapist.
When the conditions of a woman’s life change for the worse—she’s passed over for a promotion, splits up with a significant other, or, like Marilyn above, loses a loved one—her symptoms can flare up dramatically in a short period of time. Hormonal changes related to PMS, pregnancy, perimenopause, or infertility treatments can also send depression or anxiety careening from mild to unmanageable. Even positive changes can lead a woman with smiling depression to spiral downward. Three years ago, now 29-year old Krystal decided to pursue her lifelong dream of becoming a nurse. But the stress of the unknown sent the Sioux Falls, South Dakota, resident into a tailspin. She started self-harming and stopped seeing friends. Around that time, she and her husband found out they couldn’t have children, and her mother was diagnosed with cancer. In a moment of hopelessness, Krystal tried to take her own life. She ended up in a psychiatric unit for a week, where she began group therapy and medication.
“My friends and family were shocked,” says Krystal. “They said, ‘But you have the perfect life! How could you be depressed or anxious?’” The sobering truth is that over half of the women in the WH-NAMI survey who said they have smiling depression have considered committing suicide. Although it’s more severe depression that is traditionally associated with a higher suicide risk, being less severely depressed may actually give someone more energy and clearer thoughts that make her more able to complete the act, says psychiatrist Dina Goldstein Silverman, Ph.D., an assistant professor of psychiatry at Cooper University Health Care in Camden, New Jersey. That’s why it’s critical to treat your own or a friend’s sadness seriously, even if it seems manageable.
HOPE FROM DARKNESS
There’s a way out of this. Therapy, medication, and lifestyle changes (see the sidebars in this story) have helped many women with smiling depression, and they can help you too. Don’t fall into the “it’s not that bad” trap; if you’ve had symptoms every day for at least two weeks, start by talking with a close friend or family member.
That’s what Becky did. A couple of weeks after her family trip, she called her mom to apologize for leaving in such a rush, and ended up discussing the depth of depression and anxiety she felt at the lake. (Becky’s family knew she had been diagnosed with anxiety more than a decade ago, but rarely discussed it.) The two agreed to work together: Her mom asked Becky to open up to her when she’s feeling down, so she can get some help surfing those waves of sadness and anxiety. Becky also booked a therapy appointment to discuss medication, which lent more relief. “Things aren’t perfect, but my mom and I are both learning that sometimes it’s okay not to be okay,” says Becky. “And I’m learning that it’s okay to talk about it.”
Make them Listen
If you’ve tried to talk to friends and family but your concerns have been minimized, these scripts can help them understand. (If your doctor is the one not taking you seriously, ask friends for the name of a primary-care physician or a psychiatrist they like, and change M.D.s, stat.)
“How could you be depressed? Look at everything you’ve accomplished!”
“I have a hard time seeing my accomplishments; I see only what I do wrong. Can you help me by reminding me of what I do well when I get down on myself?”
“What do you have to be anxious about?”
“Anxiety doesn’t ‘need’ a reason to exist. It’s just how I feel.”
“Think of how many people have it worse.”
“When you say that, I feel like my feelings don’t matter. My problems don’t need to be worse than others’ to be valid.”
“You don’t need therapy. Just try this herbal supplement my aunt takes.”
“Thanks for the info, but I’m happy with my choice of treatment.”
These research-backed remedies can help those with smiling depression and anxiety feel—and stay—better.
COGNITIVE BEHAVIORAL THERAPY (CBT)
A therapist helps you ID negative thoughts that can keep you stuck in a funk (such as I’ll never be happy) and reframe them with a positive spin (e.g., Everybody has ups and downs. This is temporary.), often in 20 or fewer sessions. Studies show nearly two-thirds of people who use CBT had fewer depression and anxiety symptoms within 16 weeks.
INTERPERSONAL THERAPY (IPT)
This form of therapy helps you sort out symptom-triggering conflicts. For example, if constant fights with your partner or regular disagreements with a colleague are ratcheting up your symptoms, IPT can help you discover the source of the friction and guide you through problem-solving strategies to aid in resolving the issue.
Used alone or in conjunction with therapy, antianxiety or antidepressant meds—which can take up to eight weeks to start working—can help those who have difficulty getting through the day. Some patients use them for as little as six months before weaning off; others elect to stay on them for years, even permanently, if symptoms return when they try going off them.
It’s well documented that exercise can ease depression and anxiety. Now, a new study in the Journal of Alternative and Complementary Medicine found that yoga—two or three weekly sessions, combined with deep-breathing exercises—could significantly reduce depression symptoms after 12 weeks. (One breathing exercise to try: Inhale for four counts, exhale for four. Repeat until you feel calmer.)
The SMILES trial, published in the journal BMC Medicine, found, for the first time, that diet alone can curb symptoms. More than a third of patients who switched to a Mediterranean diet—cutting back on fried food, sweets, and processed meats and noshing more fish, lean meats, nuts, whole grains, and veggies—showed significantly fewer symptoms of depression during a 12-week period.