You’re in love with this wonderful person–a man who truly gets you, or a woman who makes you laugh every day. There’s a kind of connection you feel in your solar plexus and you know this is someone you want to stay with, be loyal to, and love with your whole heart.

Your relationship grows and deepens.  But after a while, something seems not quite right with your beloved.  Maybe he snapped at a waiter over nothing, which he’s never done before.  Or maybe she has started to doubt that you love her, which makes no sense because you’re more in love with her than ever.

Eventually it becomes clear:  your loved one is suffering from depression.  And precisely because it is depression and not, say, gallstones, your beloved is having trouble reaching out and explaining the experience to you.

Below are 23 things your loved one wishes you understood about depression and how it’s affecting them.

1.  They’re suffering from a brain imbalance, not a character disorder

Research has shown that in some depressed people an important part of the brain (called the hippocampus) is 9-13% smaller than in people who do not suffer from depression. And the more bouts of depression the person has suffered, the smaller it is. To complicate things a little more, research also shows that a heavy load of stress over a long period of time can shrink this area of the brain.  So, depression can start from intense emotional strain and become biological over time.

2.  Their motivation is impaired

The brain chemicals (called neurotransmitters) responsible for that the feeling we call “motivation” are dopamine and norepinephrine. If you’re lucky enough to have ample amounts of them surging through your brain, you get up every morning feeling ready to tackle your tasks and responsibilities for the day. But many who are suffering from depression have low levels, leaving them devoid of even enough motivation to get out of bed. Telling these folks they just need to start exercising or find a job is like telling someone with the flu they just need to stop throwing up. It’s not something they can instantly control.

3.  The worse the depression, the less they care…about anything

Motivation isn’t the only casualty that depressed people experience. As the brain becomes increasingly depressed, the person often experiences apathy—a lack of interest in life’s activities and relationships. Barrie Davenport gave the best description of it in her blog post on Live Bold and Bloom: “It’s white noise. Dead air. You feel like a chunk of flavorless tofu. Not happy. Not sad. Not angry. And certainly not passionate.” It is one of the most heartbreaking aspects of depression, because it creates so much interpersonal upset: loved ones fret more and more about the person’s wellbeing, but the person cares less and less about their fretting.

4.  They often feel “broken”

You may even hear them use this term about themselves. There is a sad finality to this word, so it’s important to disagree with this judgement. People with depression are not broken any more than people with diabetes or cancer are broken. It is a condition, an illness—something to address and manage. It might be a life-long challenge, but it does not mean the person is condemned to life-long pain.

5.  They don’t want to be a burden

Depression is not a ploy for attention. The last thing people with depression want is to inconvenience people they care about. They already feel bad about themselves; becoming a burden only deepens that. And yet, they need help. They need people to show up for them. So the trick is to convey your unwavering love and support for them, regardless of what it’s doing to your life. Not easy, but crucial.

6.  Their illness may show itself as deep sadness

Most people equate depression with sadness. In fact, most people will loosely describe anyone who is bereaved and crying a lot as “being depressed.”  If the person suffered through abuse, abandonment, or a significant loss as a child, it may have imprinted their sadness deep into their minds, which they basically relive every day. Without these experiences being processed in adulthood, they stay stuck in their childhood grief, manifesting as depression.

7.  Or it may show itself as anger

In my work with combat veterans, I found that many depressed soldiers experienced their depression as anger or even rage and not as much as sadness…at least not initially. (I also often found that when they felt safe enough to dig into it further, underneath that anger was profound, almost unbearable, grief and sadness from all the layers of loss they witnessed and experienced.) Uncharacteristic anger is another way depression can show itself–a sign that can be easily missed.

8.  Or it may show itself as anxiety

Research is showing more and more genetic and neurobiologic overlaps between depression and anxiety. This would explain why 90% of people with an anxiety disorder have many of the symptoms of depression and why 85% of people with depression also experience anxiety. Is this because the experience of depression makes us worried that we’ll lose our jobs or our families? Is it because anxiety disorders are so difficult to deal with that we get worn down emotionally and start to feel hopeless? Hard to tell. But increasingly, we’re understanding that there are many complex issues at play.

9.  They may be extremely sensitive to criticism

One of the least recognized symptoms of depression (specifically “atypical depression”) is an extreme sensitivity to criticism. What might have been meant as nothing more than an opinion, e.g., “Blue is a better color for you,” is perceived as a criticism that the person is wearing green. This is not a personality trait; once the depression is treated, this hypersensitivity resolves.

10.  It may have started with a specific incident

As I mentioned earlier, painful things that happen to us early in life can leave imprints on our brains that affect us our whole lives. The more powerful the experience, the more difficult it is for a child to understand and integrate it fully and therefore the bigger the impact it’s likely to have. But events in adulthood can be just as devastating, especially if it causes upheaval of one’s identity. Divorce is hard for almost everyone, but it’s hardest on those who feel that the meaning of their roles and lives have been altered because of it. A mastectomy is always painful and scary, but it can become a source of deep depression if it threatens the woman’s identity.

11. Or it may be cumulative from many incidents

Research shows that there can be a cumulative effect from a long string of “minor” events. For instance, being verbally criticized or ridiculed over many years almost always wears down the person’s sense of self-worth, which can become a depressive episode. Multiple job losses can create a new (but inaccurate) negative narrative that the person comes to believe, deepening into a depressive episode if it’s not robustly challenged.

12.  Or it may be chemical and not from any incident at all

Genetics play a role in pretty much everything, and those who have a long familial history of depression are more vulnerable to depressive episodes than those with no family history.  If the person was exposed to those family members directly while growing up, they may have also unwittingly learned negative patterns of thinking that contribute to depression.

13.  Their sleep patterns are usually way off

Some will sleep every minute they can, even to the point of sleeping through important events (like getting up in time for work!) And others have a terrible time sleeping, even when they’re exhausted. A change in sleep pattern is one of the classic signs of depression.

14.  Their eating patterns are usually way off, too

Like sleep, a change in their usual pattern of eating is almost a given. Again, some will eat compulsively trying to feel better and others have no energy or motivation to eat at all. It shows up as significant weight loss or weight gain.

15.  They may also have a lot of body pain

Sometimes people present in the doctor’s office with body pain that ends up having no medical cause.  Headaches, back pain and stomach pain are the most frequently reported kinds of body pain associated with depression, and are frequently misdiagnosed.  Most of these improve as the depression is treated and abates.

16.  They feel profoundly alone

Our culture values productivity and strength, so being crippled with exhaustion and paralyzing emotion (sad, mad, or scared) puts the depressed person at risk of being ridiculed, criticized, or in some other way degraded, all of which creates a sense of being “different” and somehow “less.” Often, the depressed person thinks the “solution” is to use all their energy to hide what’s happening from their co-workers, friends, even loved ones, which only intensifies their sense of alienation.

17.  They may frequently think about death or suicide

Alienation—that feeling of being utterly alone in the world with no one to talk to or lean on—is one of life’s most painful experiences. For some, it is unbearable and leads to thoughts of suicide as a way to end the pain. People who are severely depressed think about suicide far more often than anyone would imagine, and certainly more often than they let on.  In fact, research shows that most people who die by suicide have been “rehearsing” it in their minds for quite some time.  So it’s essential that you take this condition seriously and help your beloved get some kind of intervention.

18.  Exercise helps about 30% of those who suffer from depression

Motion improves emotion. It helps reduce anxiety, it helps dissipate anger, and it helps ease depression. Even a 10-minute walk (in an environment that feels nurturing, not stressful) can mobilize the body’s fluids and the brain’s blood flow in positive ways. Research has shown over and over again that there is a segment of the population who can completely erase their depressive symptoms through exercise, and that the more exercise these folks do, the better they feel. It’s not true, or even possible, for all of us (for instance those who are wheelchair bound or chronically ill with another disease), and it is no small task to start when you’re seriously depressed.   But it has completely changed the lives of many.

19.  Psychotherapy helps about 30% of those who suffer from depression

People who have suffered neglect, abuse, trauma, great loss, combat, or assault often need someone knowledgeable and grounded with whom to talk through their difficult experiences. Even without those major events, some people experience a significant improvement in their symptoms through psychotherapy. Those of us trained in providing psychotherapy have studied and practiced this art extensively under expert supervision. There is a long list of helpful techniques a therapist can employ that helps ease depression, but there is an equally long list of things not to do, and only someone trained will be adequately skilled to provide safe care.

20.  Medication helps about 30% of those who suffer from depression

I suffered a terrible bout of depression in my 30s that no amount of psychotherapy could fully treat. When I finally accepted my doctor’s urging to try an antidepressant, the effect was nothing short of miraculous: within 3 weeks, I had a kind of mental resilience I had never known before. The best way to describe it is that it gave me a new kind of mental shock absorbers. Instead of every pebble in life’s road feeling like a boulder, I glided over them with grace. Sometimes, medication is exactly what the person needs.

21.  It may take several weeks before an antidepressant starts to work

Don’t expect your beloved to “snap out of it” once he or she is on medication.  When prescribed, let’s say, fluoxetine (also known as Prozac), the capsule is not filled with serotonin. It’s a medication that rebuilds the serotonin receptors (among other things). That rebuilding process takes time; how much time is different for each person. For some, they start to feel better in a week or two. But lots of people take longer—up to 6 weeks—before they feel the effects.  So be patient.

22.  It may take several months to find the right medication

If the antidepressant the doctor has prescribed hasn’t improved the patient’s condition by 4-6 weeks, usually the doctor will prescribe another antidepressant. And then another, and so on, until the patient starts to feel significantly better. Unfortunately, there is no short-cut here—no blood work that will tell the doctor what to prescribe. There are some antidepressants that are better at certain things than others (for instance, escitalopram—“Lexapro”—treats both depression and anxiety, and bupropion—“Wellbutrin”—is used to treat atypical depression.) But there can be a significant period of trial and error.  They’ll need reassurance that you understand this and don’t blame them for not getting better.

23.  Friends and family who stick by them are treasured beyond words

Because of the alienation those with depression so often feel, the friends and family who stick with them and weather their storm of depression become their most trusted and appreciated allies. That kind of loyalty can be life-saving.

Depression is at nearly pandemic levels world-wide, so don’t hesitate to let others know these important points about depression.  The more we know and understand, the stronger we all are.

Featured photo credit: Josh/JohnONolan via imcreator.com

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