posted 3rd May 2021
When depression wears a smile, even psychiatrists like me can be deceived. By the time mental ill health is visible, it's probably very bad. The best risk assessment is to listen rather than look. In my everyday life, when I see someone who looks happy, I expect them to feel like that, too. I don't think about it particularly - it's a reflex. I glance casually at a smiling face and am reassured that all is well.
It takes a conscious effort to remind myself of a fact that psychiatrists know very well on an intellectual level but should perhaps recognise more: a cheerful demeanour can be profoundly misleading.
The concept of the "happy" depressive is familiar in art and life, with examples ranging from Pagliaccio to Robin Williams. It seems strange to think that people can be very depressed - with all the debilitating symptoms that entails - yet manage to hide this, sometimes even from family. Is their depression as real, or as valid, because they manage to go to work, to smile, even to crack a joke? I think it is. There may come a point when even the happy depressive will crack, unable to maintain that facade any longer. But does that mean they suffer less when smiling? No: in fact, the strain of keeping up appearances, the weight of a misplaced sense of responsibility to others, can be one of the most onerous aspects of mental ill health. The loss of the smile may even be a relief. All this is relevant to psychiatrists, because we spend a lot of time assessing risk. I have no argument with this, as of course we want to save people from harming themselves and, far more rarely, hurting others. Risk assessment is not an exact science, and we may have to be over-cautious about many to save one. At times, despite all our best efforts, we get it wrong.
The problem is that risk assessment becomes paramount, and in stretched services it may be the main purpose of contact with patients. No health professional wants to bear the heavy burden of death, possibly compounded by an inquiry and fear of loss of livelihood. This isn't just wanting to keep out of trouble, though. We don't forget the people who die; we can't suffer the pain of their families, but there will always be regret and sorrow.
When I learned about depressive disorder, I heard about melancholia. I read that people slow down, look sad or flat, their movements ponderous. They talk quietly, often with gaps. Sometimes they are agitated. Their sleep is disturbed, they may barely eat, and their thoughts are black. We have all seen these people, and they are often very unwell. But what of the smiling depressives?
It can be more complicated to assess their risk: a rigid approach may lead the psychiatrist to believe that it is negligible, and it will look negligible when recorded. But a broader, less focused conversation might reveal more. It's just difficult for the psychiatrist, with limited time, to achieve that.
My own experience is certainly that what you see is not always what you get. I feel depressed before my appearance follows suit. And at that time, if I say I feel depressed, the response will be: Well, you look fine, you seem really well. I know that people want me to be well, and that it's often no more than that, but it's quite discombobulating. Later, I may feel no worse, but haven't bothered to put makeup on, and am told: You look dreadful. That's not cheering either.
I am very aware that making an effort and slapping on some makeup does change how I am perceived, and patients are often categorised using this kind of visual shorthand. But there are pitfalls. Looking unkempt can be a sign of depressive apathy. But it could also be normal for that patient. And there can be a great deal of pressure to look reasonable, including when going to see the doctor or psychiatrist. Good presentation doesn't necessarily signal all is well.
All of these cautions apply to the often long process of recovery, too. There can be moment in depression when things start to feel better, when there is a little fragment of a thought that says: I might get well again. For me, this is one of the hardest of times. I may have started as a smiling depressive, and tumbled into classic depression, but what am I now? The advice, rightly, is often to embrace as much normality as you can, to exercise, try to see people, do things you enjoy. The problem is that you can't do these things while wearing a depressed look - you won't manage to do them, and they won't help. So if someone is foolish enough to say that I am looking well, and this jars with my still-sluggish thoughts, I will be plunged into self-denigration. I will feel pressure to return prematurely to work and my normal life. I don't know how best to solve this; unfortunately my face doesn't always map my inner feelings, and I am often heavier at this point from medication. And gaining weight - seeming "hale and hearty" - is another condition that can be mistaken for cheerfulness.
So beware the false reassurance of the smile. Appearance is less helpful a diagnostic tool than we have been led to believe. By the time mental ill health is outwardly obvious, it's probably very bad indeed. The lesson, for psychiatrists and for all of us? Listen to people; hear what they say. They may be telling you something their face can't express.
