Depression is complicated. As a non-expert, I can only say what I know from my own experience.
Not based on a randomized trial or an extensive literature review. Just based on living for 20 years with various stages of this disease. In college, I experienced my first flare-up. It was actually more like a slow burn. Life was rolling along and things were ostensibly good. Boyfriend, high GPA, great friends, good music and so much laughter in those dorm rooms. And then, things went south with the boyfriend (which in hindsight was all about my mind and nothing about him) and that became the excuse for why I was so sad and fatigued. I needed no food for days on end. I just needed to sleep for 15 to 20 hours per day. "Breakup blues" was a normal part of life, wasn't it? The thing is -- I never really recovered.
I definitely went into remission -- for many many years. But this is a chronic illness with relapsing/remitting patterns. Like multiple sclerosis, diabetes, cystic fibrosis, you have many months or years of feeling fine but you are at risk of a flare-up at any time if you aren't vigilant about your health.
And like any other disease, it looks different on each person. Some peoples symptoms will be obvious. Their sadness is palpable. It's painful to watch. Their shuffling gait, hollow eyes, stained shirts and heavy limbs. They look like they're walking through quicksand. There's no question that they suffer. That they are sick. That they desperately need medical attention. That they may or may not recover. Because, sadly, like any chronic illness patient -- some respond to therapy (pharmacotherapy and psychotherapy) and some do not. Like any chronic illness patient, some will die from their disease.
When I was rotating through Bellevue, there was a sweet sweet man who had been living on the unit for years on and off. He would briefly recover and then be readmitted shortly after with another relapse. The psychiatrist explained to me that he was "terminally ill," which confused me at the time since he looked so healthy. She explained to me that this patient had tried every anti-depressant on the market as well as multiple rounds of electroconvulsive therapy. His disease was refractory, unresponsive... terminal. He would die of his disease. The only question was when.
Depression can also be much more subtle. It can be tricky. Because you could look awfully normal and functional and funny and smiley even. You can go to work and get the job done. You could go to the grocery store, write a grant, drive carpool, submit research proposals and mop your floors. You could exercise and nurse babies and figure out how to solve complicated equations and balance budgets. You can laugh often. You can go shopping and look fabulous. But you are still, at your core, experiencing life differently than the non-affected person.
You aren't sure you know how to experience joy anymore. True joy. Or even true sadness, anger, or anxiety. You have become a well-oiled machine who knows what to do but not how to feel.
Dysphoria is a general term for feeling unwell or unhappy. Its from the Greek -- "difficult to bear." It so perfectly describes this kind of depression. It's difficult, but not impossible, to bear. That's why we look so functional -- because it's not the walking through quicksand depression. It's more like walking through seaweed- difficult but not impossible.
This kind, if it stays in this stage, usually doesn't kill you. But it robs you. It takes away joy and connectedness, and the experience of being alive on this earth with feet rooted in the ground. It steals relationships and it steals your kindness.
Having never experienced the quicksand, terminal depression, I have to drop to my knees with my forehead to the earth and thank the creator of the universe for good DNA and for laboratories that found serotonin and dopamine and the drugs that keep them bathing my brain. And for a brain that responds to those drugs. Because in my non-expert opinion -- that is the only difference between me and Robin Williams or the other people who die in quicksand every year. My disease is responsive. Maybe theirs wasn't.
So whether its quicksand or seaweed or some combination of the two (I call that "quickweed" depression), my hope is that people will start to come forward and say -- "I am in the quicksand, please help me." And that we will listen. Because there should never be shame in illness.