Pop quiz: What are the three most common symptoms of depression? If you said any of the following: sadness or a low mood, tearfulness, appetite changes, and either insomnia or excessive sleeping, you would be right on target. Or would you? Up until very recently, the medical definition of depression stressed exactly those symptoms as necessary in order to diagnose depression. As it turns out, new research exploring a slightly expanded notion of depression may be more accurate and more inclusive. At present, in order to diagnose a depressed episode in adults, a depressed mood (sadness, or feeling “blue,” low or unhappy) must be present for most of the day, every day, for at least two weeks, or you must experience a loss of pleasure or enjoyment in activities you used to enjoy. Based on these criteria, the distribution of depression in the general population was skewed toward women—it seemed that many more women tended to become depressed than men.
In children and adolescents, when diagnosing depression the mood requirement is different: it is possible to diagnose depression based on the presence of an irritable mood and meeting the other diagnostic criteria. Some children, it seems, express their sadness as anger, irritability, touchiness, having a short fuse, and sometimes even more serious or severe angry behavior is noted. A good doctor or therapist, conducting a thorough clinical interview with the child and parents, would often be able to piece together a picture of depression from children that at first glance appears to be anything but sad: angry, acting out, even violent kids and their families have benefited greatly by receiving treatment for the underlying depression that may cause the angry acting out behavior. But can adults also be diagnosed with irritable depression? Not yet, but the new research findings, published by JAMA’s Psychiatry journal, may be a step in that direction. The research was undertaken in part to explore a pair of statistics that seemed to contradict each other: diagnosing according to the traditional criteria, women tend to become depressed much more often than men, but men tend to be much more likely to commit suicide. Most mental health professionals and researchers believe suicide to be linked to depression, so the statistics just didn’t seem to make sense. Re-conceptualizing the symptoms of depression to include what has in the past been called “irritable” or “hostile” depression may help connect the dots. Understood within the children’s mental arena as an alternative way in which depression “expresses” itself, irritable depression is a bona fide subtype of depression, understood and treated as such by psychiatrists and therapists alike.
Symptoms of Irritable Depression in Adults
If depression doesn’t necessarily look like depression in adults, and especially among adult men, then what might it look like? How could a spouse, friend, or co-worker recognize depression in men? According to the study, outward manifestations of depression that have previously been misunderstood as unrelated to depression include substance abuse or alcoholism, or other addictive behavior such as workaholism, angry outbursts, aggression and risk-taking behavior. Related symptoms may include poor concentration or trouble focusing. And remember, in order to diagnose depression, or any other major mental illness, these symptoms must represent a change from prior functioning. So when is anger actually depression and when is anger just plain anger? Diagnosing an irritable depression in adults requires skill on the part of the clinician and time spent in session creating a real therapeutic bond. Not as simple as running down a checklist of symptoms, developing a relationship with the clinician can really help you end up with an accurate diagnosis. In the case of irritable depression, teasing apart anger, rage, angry behavior, substance abuse and depression takes some time. Developing the kind of trust that leads to revealing enough of the overall picture to allow the professional to glean all the facets of the situation is an important piece of the puzzle as well. To further complicate the picture, depression is not the only mood disorder that may show up as anger issues or substance abuse. People with bipolar disorder, formerly called manic-depression, often struggle with sadness and anger and are prone to acting out these feelings or self medicating using drugs or alcohol. Some people with bipolar disorder experience what are called mixed states, in which the symptoms of both depression and mania happen at the same time. The resulting emotions would be very similar to the symptoms the researchers described as a new way to understand depression in men. Whether depression needs to be understood more broadly or screening for bipolar mixed states needs to be more thorough, it is a positive step forward to understand that men are suffering even if they are not showing outward symptoms of sadness. Understanding the statistics and working toward preventing suicides and providing appropriate treatment for all mental illnesses are positive moves that benefit all of us. Treatment works and feeling better is possible, even if you’ve been angry and struggling with addiction for a long time.