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Asymptomatic Depression:
Hidden Epidemic and Huge Untapped Market

Methodius Isaac Bonkers, M.D., Principal Investigator
Bonkers Institute for Nearly Genuine Research

In recent years, antidepressant sales have skyrocketed beyond the pharmaceutical industry's wildest dreams.   Yet despite widespread screening programs and aggressive marketing campaigns designed to raise mental health disease awareness, a significant percentage of the population remains undiagnosed and untreated.   Estimates vary, but research suggests nearly a third of American adults have never been diagnosed with any mental disorder.   Precisely this segment of the population must be targeted for intervention if pharmaceutical profits are to continue rising at their current rate.

One way to increase the prevalence of a disease is to broaden its diagnostic criteria.   By providing physicians with an ever-growing laundry list of signs and symptoms to evaluate (insomnia or oversleeping, poor appetite or overeating, constant crying or inability to cry, apathy or hostility, fatigue or restlessness, and so on), the number of potential clients/patients is greatly expanded.   However, a major flaw in this strategy is that it focuses exclusively on those who complain of sickness, while completely overlooking those who feel well.   The present article explores the novel hypothesis that patients who feel well are, in fact, patients who need treatment.

Understanding depression and its causes

Depressive disorders often co-occur with anxiety or substance abuse and are a leading form of disability in the United States.   Depression may strike any time without warning.   Researchers have identified the five primary causes of mild, moderate and severe clinical depression:
      1.   Imbalance of key chemical neurotransmitters in the brain;
      2.   Chronic low-grade hopelessness generated by early childhood trauma;
      3.   Marriage to the wrong person;
      4.   Sudden realization of the essential absurdity of life;
      5.   Ecological catastrophe on a scale never before seen in human history.

Other factors which might trigger a depressive episode include:
      *   having either too much or not enough of something;
      *   being trapped in an utterly hopeless situation with no way of escape;
      *   remorse, guilt, shame, failure, disappointment, frustration, grief, heartache, pain or loss of some kind;
      *   infestation of household pests such as termites or rodents;
      *   omega-3 deficiency from not eating sufficient quantities of cauliflower and other vegetables;
      *   leaky faucet, clogged drain or similar plumbing problem;
      *   global economic collapse, thermonuclear war, mass starvation, genocide, etc.

Obviously, anyone who feels depressed is depressed, but what about those who never complain of depressive feelings?   The sickest members of our society may be those who maintain a cheerful attitude in the midst of devastation, chaos and despair.   Turning our attention to patients who insist they feel fine even as the entire world crumbles around them, we immediately recognize something seriously wrong with these individuals.   Their condition arises from a particularly insidious and virulent strain of depression, difficult to detect.   Identified by the scientific name dolor occultus ("hidden pain"), asymptomatic depression is a serious and persistent mental illness which may be far more prevalent than previously thought.   Compounding the tragedy, in most cases patients remain untreated because they are entirely unaware of their disease.

Recognizing signs and symptoms

Familiar signs and symptoms of chronic clinical depression are easily recognized:
      * slumped shoulders;
      * downcast eyes;
      * inability to concentrate;
      * may go months without dusting behind the refrigerator;
      * inclination to see the glass as half empty;
      * tendency to worry about nuclear proliferation, vanishing coral reefs,
          mounting budget deficits and the legacy we're leaving our children.

Only a trained medical professional can properly identify the subtle signs of asymptomatic depression:
    * rosy cheeks;
    * sparkling eyes;
    * sunny disposition;
    * optimistic about the future despite all evidence to the contrary;
    * invariably sees the glass as half full;
    * doesn't mind if the glass contains deadly bacteria and toxic chemicals.
Which patient suffers asymptomatic depression?

The patient's cheerful countenance is a sure sign of asymptomatic depression.
Images generated utilizing sophisticated suprafacial photoscopic scanographic device
(Polaroid camera) to detect putative axiomatic biochemical imbalance within the brain.
Patient on right exhibits classic signs of asymptomatic depression.

Simplifying diagnosis, screening, intervention and treatment

Concerns about underdiagnosis and undertreatment of depression have led to widespread support for routine diagnostic screening in the form of standardized symptom checklists and simple written or verbal tests administered to patients.   Arroll, Khin and Kerse (2003) report impressive results when patients are asked two questions:

  1.   During the past month have you often been bothered by feeling down, depressed, or hopeless?
  2.   During the past month have you often been bothered by little interest or pleasure in doing things?

Brief yes-or-no questionnaires have proven remarkably efficient in detecting cases of depression, although false positive rates of 30% and false negatives of 0.4% clearly leave some room for improvement.   Accurate and comprehensive screening of an invisible or hidden disability like asymptomatic depression requires the use of precise diagnostic tools much more sophisticated than a simple two-question quiz.   Experts recommend a rigorous one-question quiz:

      1.   Do you feel depressed, yes or no?

A single-item questionnaire not only simplifies screening, but also facilitates diagnosis, validates testing, justifies intervention and maximizes treatment.   Patients responding "Yes" are diagnosed with depression and treated accordingly.   Patients responding "No" are diagnosed with asymptomatic depression and treated accordingly.

In all cases, whether patients respond Yes or No, current evidence-based treatment protocols dictate prudent pharmacological intervention with a selective serotonin reuptake inhibitor (SSRI) such as Lexapro or Zoloft and/or serotonin-norepinephrine reuptake inhibitor (SNRI) such as Cymbalta or Effexor.   Both SSRI and SNRI agents are proven to work equally well for mild, moderate or severe major depressive and dysthymic or cyclothymic mood disorders including chronic, clinical, residual, refractory, treatment-resistant, subsyndromal and/or asymptomatic depression.

Although their precise mechanism of action is not well understood, antidepressants appear to relieve depressive symptoms through an active placebo effect.   Common adverse reactions including insomnia, irritability, impotence and incontinence effectively convince patients of the medicine's potent neurophysiological properties, somehow making them feel better.

In cases of asymptomatic depression, antidepressants have a paradoxical effect.   Patients who feel fine before taking the medication subsequently grow depressed as they endure side effects ranging from diarrhea, nausea and heart palpitations to grand mal seizures, headache and tremors.   Emotional distress typically increases as physical health declines — a sure sign treatment is working.   Once the patient's asymptomatic depression is completely cured, the physician may confidently diagnose major depressive disorder and treat the patient accordingly.


Arroll B, Khin N, Kerse N.   Screening for depression in primary care with two verbally asked questions: cross sectional study.   British Medical Journal, Vol. 327, No. 7424 (15 Nov. 2003), pp. 1144-1146.

Ayd, FJ.   Recognizing the Depressed Patient: With Essentials of Management and Treatment.   New York, Grune & Stratton, 1961.

Bentall, RP.   A proposal to classify happiness as a psychiatric disorder.   Journal of Medical Ethics, Vol. 18, No. 2 (June 1992), pp. 94-98.

Kirsch, I.   The Emperor's New Drugs: Exploding the Antidepressant Myth .   New York: Basic Books, 2010.

Regents of the University of Michigan.   Beyond Sadness: Bridging the gap between emotional and physical symptoms of depression. Ann Arbor, MI, 2002.

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