The diagnosis and treatment of hidden depression

Abstract

Depression should not be too difficult either to diagnose or to treat. The characteristic symptoms—depressed affect, psychomotor retardation, vegetative signs, ideas of suicide and worthlessness—are straightforward and easy to recognize. The procedures for combining antidepressant medication and psychotherapy are well understood and usually effective. Yet, clinicians tend to miss the diagnosis with distressing regularity. Part of the problem is that the symptoms are not always characteristic. Depression often comes in atypical or hidden forms that confound the diagnostician. But even if the disguise is penetrated, the psychiatrist is apt to conclude that, because the symptoms are “soft,” the depression is “reactive” and should be treated by psychotherapy alone, even when there are underlying biological determinants. My purpose here is to discuss several typical cases of atypical or hidden depression that have been successfully treated by combined pharmacotherapy and psychotherapy. We shall be on the lookout for historical, characterological, and symptomatic clues that tip off the diagnosis and suggest a combined etiology and a role for combined treatment.