There is a phrase I often hear during consultations. Usually accompanied by a downward gaze and a barely audible voice: “Doctor, I wasn’t like this before.” It is not a complaint; it is a confession. Behind those words lies someone who has spent months—sometimes years—trying to live well. All the while carrying a burden they cannot name. By the time they finally reach a consultation, they have often already filtered their experience through their own internal biases. “This is just weakness,” “Others have it worse,” or “I should be able to handle this on my own.”
Today, I want to talk to you about major depression. So that silent companion that does not always manifest as tears or overt sadness. It often disguises itself as fatigue, irritability, physical pain, or simple indifference. Identifying it correctly is the first step toward moving past the misconception that it is merely laziness. A fleeting lack of motivation, or a “bad temper” when, in reality, it is a form of suffering.
What Major Depression Is and Isn’t
Let’s start with the basics. Major depression, also known as clinical depression, is neither a normal state of sadness nor a typical reaction to a loss. It is a clinical syndrome that affects one’s mood, neurovegetative functions (such as sleep, appetite, and energy levels), cognition, and behavior. The fundamental difference between this and everyday sadness lies in its persistence and the functional impairment it causes.
According to the American Psychiatric Association’s *Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision* (DSM-5-TR). A major depressive episode is defined by the presence of at least five symptoms over a two-week period. Symptoms that represent a clear change from the individual’s previous level of functioning. At least one of these must be either a depressed mood or a loss of interest or pleasure in nearly all activities.
Other possible symptoms include significant changes in weight or appetite, insomnia or excessive sleep, psychomotor agitation or retardation observable by others. Fatigue or loss of energy, feelings of worthlessness or excessive guilt, difficulty thinking or concentrating, and recurrent thoughts of death or suicidal ideation. This is not a checklist for self-diagnosis, but rather a guide to understanding that depression is a collection of manifestations that can present in very different ways from person to person.
Major depression does not discriminate based on age, sex, educational level, or social status. The World Health Organization (WHO) estimates that, in 2023, approximately 5.2 percent of adults worldwide suffered from depression. A condition occurring about 1.5 times more frequently in women than in men. It is not a character flaw, it is not a lack of willpower, and it is not something that can be resolved simply by “trying harder.”
There is a distinction that I find essential, which the psychiatrist Kay Redfield Jamison—herself a patient—expressed with great clarity: “In grief, death causes the pain; in depression, death is the solution to the pain.” This statement captures something that is difficult to explain using technical jargon: in grief, pain has an object, a cause, and a meaning. In depression, the pain turns against one’s own existence, and death ceases to be a source of fear, becoming instead an imagined way out.
The Unexpected Faces
Depression does not always look the way we might expect. Not everyone arrives in tears. Many come complaining of insomnia, vague aches and pains, a lack of energy, or an inability to concentrate at work. The literature indicates that patients rarely report typical depressive symptoms spontaneously. Instead, they tend to mention nonspecific complaints such as sleep disturbances, loss of appetite, general weakness, or persistent pain.
In children and adolescents, for instance, a depressed mood may manifest as irritability rather than sadness. In older adults, depression can be mistaken for age-related cognitive decline or the “expected” listlessness that often accompanies retirement. And in many men, sadness transforms into anger, social withdrawal, or substance use.
The psychologist and philosopher William James—who knew the depths of such despair firsthand. He described the experience using an image that is still cited today: “Depression is a living, concrete torment. A kind of psychic neuralgia, utterly unknown to normal life.” This metaphor is apt because depression causes pain sometimes in the body. Always in one’s lived experience and because those who have not experienced it themselves can hardly imagine what it is truly like.
Also that is why I insist that if someone close to you has changed, if they no longer enjoy what they once did. Or if they have become a different person in how they engage with the world, we should not simply wait for it to pass. This disorder tends to become chronic if left untreated, and every untreated episode increases the risk of future relapses.
Why does depression occur?
The honest answer is that we do not fully know, and there is likely never just one single cause. Rather, it involves a convergence of biological, psychological, and social factors. Genetics play a role in approximately one-third to one-half of cases, with a higher prevalence among first-degree relatives. Other contributing factors include hormonal systems, neurotransmitters, adverse childhood experiences, significant losses, and chronic stress.
The WHO summarizes it clearly: “Depression results from a complex interaction of social, psychological, and biological factors.” And those who have experienced adverse life circumstances are more likely to develop it. This is important because it debunks two opposing myths: the idea that depression is purely biological and can be resolved solely with medication. And the notion that it is purely psychological and can be overcome through willpower alone. Neither of these is entirely true.
Psychiatrist Viktor Frankl, the founder of logotherapy, introduced a dimension that is often overlooked: “Depression, aggression, and addiction cannot be understood unless we recognize the existential vacuum that underlies them.” Of course, not all depression is a crisis of meaning, and reducing it to that would be a mistake. Yet, Frankl offers a valuable insight: behind the symptoms, there is often a question about meaning. About the place one occupies in one’s own life. That question deserves to be heard, not merely medicated away.
What actually works
It is essential to understand that major depression is treatable. The WHO states it unequivocally: effective treatments exist for mild, moderate, and severe depression. The cornerstones are psychotherapy and in moderate to severe cases: antidepressant medication. For mild depression, psychotherapy is usually the first step, with no need for medication.
The most commonly used antidepressants today are selective serotonin reuptake inhibitors (SSRIs). They have a broad therapeutic window and are relatively easy to administer. When prescribed appropriately, they help the brain return to a healthier level of functioning, enabling the individual to engage effectively with psychotherapy and reclaim their life.
However, medication and therapy are not the only essential elements. It is also necessary to restore healthy sleep patterns, incorporate physical movement, reconnect with others. Learn to ask for help without shame, and understand that seeking support is not a failure, it is an act of exercising one’s right to self-care.
An invitation
Carl Gustav Jung, whose work shaped our understanding of the human psyche, offered an image I would like to share with you: “Depression is like a woman in black. If she appears, don’t shoo her away; instead, invite her to the table and listen to what she has to say.” Do not take this as a clinical prescription. Severe major depression cannot be resolved simply by listening to it; it requires treatment. You can, however, view it as an attitude: the stance of someone who does not flee from their distress or feel ashamed of it, but rather dares to look it in the eye and seek help.
If anything you have read today resonates with you—if you have been feeling this way for weeks or months—I offer you a simple invitation: do not let it go unaddressed. Do not wait until you hit rock bottom to seek professional help. Major depression is best treated when detected early, and the first step the most difficult and the bravest is to say out loud: “Something is going on with me, and I need help.”
Also If this doesn’t apply to you today, perhaps it applies to someone close to you. Sometimes, the best gift we can offer someone who is suffering is a non-judgmental question: “How are you really?” And then, simply listening.
I invite you to read my next post this coming Monday. In the meantime, take care of yourself, and look out for those around you as well.
- Major Depression: A ‘Silent Companion’ That Doesn’t Always Come with Tears or Obvious Sadness - 9 de November de 2026
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