Smiling Depression

Sean Jackson
Author: Sean Jackson Medical Reviewer: Morgan Blair Last updated:

Smiling depression occurs when people are depressed yet have few or none of the tell-tale signs of depression, at least outwardly. Inside, however, the pain of depression runs deep. Though smiling depression is a non-clinical term and is not in the DSM-5, it is considered a form of major depressive disorder with atypical features.[1]

What is smiling depression?

Smiling depression is like a mask or a facade. On the outside, someone with smiling depression appears to be happy and completely content. Moreover, this facade isn’t just for others – many people with smiling depression don’t realize they are depressed.[1]

However, lingering under the surface are the typical symptoms of depression, like feelings of inadequacy, hopelessness, despair, and worthlessness. In many cases, people with smiling depression have struggled with depression, anxiety, or both, but maintain the mask of happiness out of fear of being judged by others.

So, even if a person is aware of their depressive symptoms, they maintain a picture of normalcy and continue with their day-to-day lives as though nothing is wrong. The ability to conduct the business of everyday life lends itself to another non-clinical term used to describe smiling depression – high-functioning depression.[2]

Smiling depression symptoms

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) outlines the criteria for a major depressive episode. These criteria, which describe common symptoms of depression, are paraphrased as follows:[3]

  • Depressed mood for more than two weeks, including five or more of the following symptoms nearly every day:n
    • Depressed mood most of the day
    • Marked reduction of interest in once-pleasurable activities
    • Significant weight changes
    • Sleep disturbances like hypersomnia or insomnia
    • Psychomotor agitation or retardation
    • Loss of energy
    • Feelings of worthlessness or excessive guilt
    • Reduced ability to concentrate and indecisiveness
    • Recurrent thoughts of death or suicidal ideation
  • Symptoms pose significant distress in functioning
  • The symptoms are not better explained by a substance or a medical condition, including schizophrenia, schizophreniform disorder, schizoaffective disorder, delusional disorder, or other schizophrenia or psychotic disorder
  • No manic episodes have occurred

In addition to these core depression symptoms, there are other smiling depression symptoms of which to be aware.

For example, the DSM-5 notes that major depression with atypical features involves milder symptoms overall.[3] This goes back to the earlier point that some people with smiling depression don’t even realize they’re depressed.

Additionally, atypical depression must include mood reactivity and at least two of the following:[3]

  • Extreme difficulty walking
  • Hypersomnia
  • Rejection hypersensitivity
  • Overeating or weight gain

These symptoms may be difficult to identify, if not wholly absent, when a person is with others. However, the symptoms might manifest when a person is by themselves.

Furthermore, low-grade symptoms – negative thinking, self-criticism, irritability, and aches or pains associated with atypical depression – might be written off as regular ups and downs or as part of another psychological or physiological ailment.[2]

Smiling depression causes

Smiling depression symptoms may be caused by multiple factors, just like any other mental health issue. The cause may include a combination of genetic predisposition for depression, environmental factors (e.g., extreme stress, grief, etc.), and psychosocial factors (e.g., persistent interpersonal rejection).

Likewise, biology plays a part in smiling depression. For example, people with depression have abnormal levels of serotonin, norepinephrine, and dopamine in the brain. Likewise, GABA, glutamate, and glycine are believed to be involved in the development of depression as well.[4]

In addition, multiple risk factors increase the chances of someone developing depression. These include:[5]

  • Physical health problems (e.g., heart disease, diabetes, cancer)
  • Medications (e.g., some medications have side effects that contribute to depressive symptoms)
  • Negative life events (e.g., the death of a loved one, job loss, divorce)
  • High levels of childhood anxiety

Smiling depression diagnosis

As noted earlier, the DSM-5 offers specific criteria for diagnosing major depression with atypical features, the subtype under which smiling depression falls. Refer to the earlier section on symptoms to review those criteria again.

Remember, though, that smiling depression is not a diagnostic term, nor is high-functioning depression. Instead, these are colloquial terms used to describe this type of depression. Remember as well that smiling depression symptoms can be difficult for people to recognize, both as someone with the disorder and as a mental health professional attempting to make a diagnosis.

To aid in a smiling depression diagnosis, a mental health professional might use assessments like the Beck Depression Inventory, Hamilton Depression Rating Scale, or Geriatric Depression Scale.[6] Clinicians might also rely on observations (their own or those from people familiar with the patient’s circumstances) to assist in making a diagnosis.

Other methods of diagnosis typically involve ruling something else out. For example, a physician might conduct a physical examination and order blood work to rule out the patient’s depressive symptoms resulting from a physical issue.

Is smiling depression dangerous?

Like any depression, some risks are inherent to smiling depression, particularly suicide. Where people with more common types of depression might lack the energy to even get out of bed, people with atypical depression usually don’t have this issue. Furthermore, they might have enough energy and focus to make a plan for their death and carry it out.[1] People with smiling depression may also be may also be at a higher risk of suicide due to the lack of warning signs that the individual is even struggling with depressive symptoms, which would make intervention less likely.

Additionally, studies show that depression is associated with a higher risk of:[7]

  • Self-harm
  • Premature mortality
  • Aggression against others
  • Committing violent acts against others

Smiling depression treatment

Though a hallmark feature of smiling depression and other forms of depression is a feeling of hopelessness, there is hope it can be treated. In fact, there are many ways to treat this condition and do so with very high efficacy.

Self-help strategies like the following can help you identify how you feel, assess your mental health, and make positive strides toward better mental health:[8]

  • Sit with your feelings and try to identify what you feel and why. Tracking your feelings in a mood journal can help.
  • Resist the urge to isolate yourself from others. Instead, reach out to loved ones for help.
  • Eat a healthy, well-balanced diet.
  • Avoid using or abusing substances like alcohol.
  • Exercise regularly to boost mood and cope with stress and anxiety.
  • Stick to a traditional sleep routine to maintain restful sleep at night and combat the desire or need to stay in bed during the day.

Of course, if your symptoms are too much for you to bear on your own, it’s important to contact your physician or mental health provider for assistance. In many cases, the treatment for smiling depression includes a combination of therapeutic interventions and medication.

Some of the most common treatments and medications for depression include:[9]

  • Cognitive-behavioral therapy is a short-term talk therapy focusing on changing your thoughts to change your behaviors.
  • Psychodynamic therapy is a long-term talk therapy focusing on the unresolved or unconscious conflicts of the past that lead to depression.
  • Antidepressant medications are effective in enhancing mood and mitigating symptoms of depression by working on related neurotransmitters in the brain. Selective serotonin reuptake inhibitors (SSRIs) like Prozac and Paxil are the most popular because they have fewer side effects than most antidepressants.
  1. Coward, L. (2016, September 2). What you need to know about smiling depression. National Alliance on Mental Illness. Retrieved May 25, 2023, from
  2. Children’s Hospital of Orange County. (2022, November 11). What is ‘high-functioning depression’ and ‘high-functioning anxiety’? Retrieved May 25, 2023, from
  3. Columbia University Primary Care Online Resources and Education. (n.d.) Diagnosing mood disorders. Retrieved May 25, 2023, from
  4. Bains, N. & Abdijadid, S. (2022, June 1). Major Depressive Disorder. National Library of Medicine. Retrieved May 25, 2023, from:
  5. National Institute of Mental Health. (2023, April). What is depression? Retrieved May 25, 2023, from
  6. American Psychological Association. (2023, January). Depression assessment instruments. Retrieved May 25, 2023, from
  7. Fazel, S., Wolf, A., Chang, Z., Larsson, H., Goodwin, G. M., & Lichtenstein, P. (2015). Depression and violence: a Swedish population study. The Lancet Psychiatry, 2(3), 224–232. Retrieved May 25, 2023, from
  8. National Health Service. (2022, September 6). How to cope with depression. Retrieved May 25, 2023, from
  9. National Library of Medicine. (2020, June 18). Treatments for depression. Retrieved May 25, 2023, from
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Sean Jackson
Author Sean Jackson Writer

Sean Jackson is a medical writer with 25+ years of experience, holding a B.A. degree from the University of Nottingham.

Published: Aug 22nd 2023, Last edited: Sep 22nd 2023

Morgan Blair
Medical Reviewer Morgan Blair MA, LPCC

Morgan Blair is a licensed therapist, writer and medical reviewer, holding a master’s degree in clinical mental health counseling from Northwestern University.

Content reviewed by a medical professional. Last reviewed: Aug 21st 2023