More than sadness

Most people picture depression as crying and hopelessness. In reality, many of the defining symptoms are the ones nobody names — which is why so many cases go unrecognised for years.

• Irritability, short temper and a low tolerance for noise or demands.
• Unexplained aches, headaches and digestive problems that do not respond to usual treatment.
• Indecision and a foggy, slowed mind that people mistake for laziness or burnout.

People can meet the criteria for depression while holding down a job, parenting and appearing entirely fine. The functioning is real — and so is the illness, and so is the cost of maintaining the performance.

• 'High-functioning' is a description, not a diagnosis. The condition underneath is the same.
• The effort of appearing fine is itself exhausting and tends to worsen the depression over time.
• Because the outside looks intact, these are often the people who get help last.

Depression is a whole-body illness. Fatigue, pain and appetite change are not consequences of feeling low — they are part of the condition.

• Sleep changes run both ways: inability to fall asleep, or sleeping far more than usual.
• Appetite and weight commonly shift in one direction or the other.
• Chronic pain and depression aggravate each other, which is why treating both matters.

Men are less likely to be diagnosed with depression, and more likely to die by suicide. A large part of the reason is that depression in men often looks like anger, risk-taking and alcohol rather than sadness.

• Watch for irritability, aggression, reckless behaviour, overwork and withdrawal from family.
• Alcohol and substance use frequently mask depression in men and make it worse.
• Men are less likely to describe emotional symptoms and more likely to report physical ones.

Depression affects women at roughly twice the rate of men, and the risk shifts with hormonal and life-stage transitions — which is why it is worth understanding in that context rather than in isolation.

• Risk rises around puberty, in the premenstrual phase, postpartum and through perimenopause.
• Premenstrual dysphoric disorder and postpartum depression are distinct, treatable conditions.
• Other drivers include caregiving load, gender-based violence, financial strain and single parenting.

Bipolar disorder involves episodes of depression and episodes of abnormally elevated or irritable mood. It is not ordinary mood swings, and it is frequently missed because people seek help during the depressed phase only.

• Depression that is severe, early-onset, atypical or unresponsive to antidepressants should prompt a check for bipolar disorder.
• Treatment is different: antidepressants alone can trigger a switch into mania.
• Mood stabilisers are the foundation of treatment, with psychological therapy alongside them.

Mania and hypomania sit on the same spectrum but differ in severity and in how much they disrupt life. The distinction decides the diagnosis and the treatment.

• Mania causes marked impairment, often with psychosis, and may require hospital admission.
• Hypomania is milder, lasts at least four days, and does not cause major disruption — though others may notice the change.
• Both include reduced need for sleep, racing thoughts, increased activity and unusually expansive mood.

South Africa's high-altitude winters bring shorter days and less daylight, and a subset of people experience recurrent low mood in the same season each year.

• The pattern is the key feature: symptoms that begin and lift at roughly the same time annually.
• Morning daylight exposure is the most effective and accessible intervention.
• If symptoms are significant or recur each year, plan treatment before the season starts rather than during it.

Persistent depressive disorder is a chronic, lower-grade depression lasting two years or more. Because it is mild relative to a major episode, it is often dismissed — by the person living with it most of all.

• The defining feature is duration: low mood most days for at least two years.
• People often describe it as 'just how I am' and cannot recall feeling differently.
• It still causes real impairment and responds to the same treatments as other depressive disorders.

Diagnosis is a structured clinical assessment, not a questionnaire. Treatment is stepped, reviewed and matched to severity — and most people improve.

• Assessment covers duration, function, risk, physical causes and any history of elevated mood.
• Mild depression is usually treated with therapy and lifestyle change; moderate to severe often needs medication too.
• If the first treatment does not work, that is information, not failure — the next step is to adjust the plan.

Support from family and friends measurably improves outcomes. It also requires boundaries, because caring for someone with depression is genuinely hard work.

• Be specific and practical: 'I will drive you on Thursday' helps more than 'let me know if you need anything'.
• Do not argue with the illness or demand the person snap out of it — but do keep inviting them.
• Protect your own sleep, support and limits; burnout helps nobody.