While some people who are battling against depression aren’t afraid to reach out for help, others may choose to suffer in secret.

More people struggle with depression than you may assume. In fact, according to the 2017 U.S. National Survey on Drug Use and Health, over 17 million Americans – or more than 7 percent of the adult population – had experienced major depressive spells within the past 12 months. And as a result, this may mean that there’s someone in your life who is battling mental health issues – even if they’re reluctant to tell you about them. But while an individual with depression may not always be willing to open up about their experiences, there are still ways in which you may be able to tell that they are ill – such as these 20 signs, for instance.

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20. Poor-quality sleep

According to a study published in the journal Sleep in 2005, people who suffer from insomnia are nearly ten times more likely to go on to experience depression than those who experience proper nights of rest. And as depression may in turn lead to further issues with sleeping, a vicious cycle may ultimately develop without proper treatment.

But insomnia isn’t the only condition to potentially impact upon an individual’s mental health. When Stanford University professor Maurice Ohayon conducted a survey of close to 19,000 Europeans in the 1990s, for instance, he discovered a potential link between depression and breathing-related sleep disorders. So, if a loved one has sleep apnea, see if they can invest in a CPAP machine, as a 2007 clinical study suggests that the device may have a marked effect on symptoms of depression.

19. Lack of appetite

And problems with sleep are by far the only potential indicator that someone may be battling depression; a lack of appetite may be a sign, too. That said, a loss of interest in food isn’t always a symptom of an underlying psychological illness. Instead, then, it’s worth determining whether other health issues are at play.

Yes, a person’s appetite may be affected by something as benign as an upset stomach or a cold. Digestive problems – such as Crohn’s disease – may also be the culprit. In any case, a trip to the doctor is in order if the desire to eat doesn’t improve over time.

18. Consuming excessive amounts of alcohol

While the occasional beer or glass of wine may not have that detrimental an effect on health, alcohol abuse is altogether more damaging. And although drinking excessively may not in itself be a sign of depression, turning to the bottle on a more than regular basis could be a red flag.

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One of the reasons why alcohol may become a crutch for some with depression is its ability to temporarily mask our true feelings – even from ourselves. And, of course, booze’s propensity to make us feel sleepy may seem to provide an easy fix for insomnia sufferers. The biggest problem, however, is that as alcohol is itself a depressant, it may only make a low mood more acute.

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17. Being unsociable

As The Depression Cure author Stephen Ilardi explained to WebMD, “When we’re clinically depressed, there’s a very strong urge to pull away from others and to shut down.” However, even if some alone time seems a reasonable recourse, Ilardi has warned against giving in to this urge, adding, “[Social isolation] turns out to be the exact opposite of what we need.”

You see, talking to a sympathetic party about feelings of depression is often one of the keys to recovery, and so this makes withdrawing from the social limelight somewhat of a counter-productive task. Indeed, as Ilardi has further explained, “Social withdrawal amplifies the brain’s stress response. Social contact helps put the brakes on it.”

16. Changing their language

While you don’t need to be a qualified linguist to notice when someone is switching up their vernacular, it’s somewhat harder to determine which – if any – changes in speech point to depression. Fortunately, though, research published in the journal Clinical Psychological Science in 2018 has pinpointed certain words that tend to rise to the fore in those with mental health issues.

And perhaps unsurprisingly, the study in question suggests that depression sufferers may tend to lean toward negative words – “sad” or “upset,” for instance – when talking. Then there may be an increased use of “I” or “me” rather than “they” or “them,” which implies, perhaps, that an individual has become solipsistic.

15. A cry for help that is covered up as a ‘joke’

If someone typically has a rather dark sense of humor, they may use a wisecrack or two to downplay their issues. However, such a gambit may make it difficult to discern a genuine hint at depression from a mere gag. As teenager Ayisat Bisiriyu has admitted in a 2018 piece for YR Media, “It makes me anxious when I hear a person laugh about how ‘bleach is the best drink to drink’ and how ‘they’d rather kill themselves than go to math.’ These jokes seemed innocent, but I no longer know who’s joking and who’s crying on the inside.”

Owing to such quips, it may be more difficult to assess when someone truly is suffering from depression – and creating an environment where every flippant remark is carefully weighed up may prove tiring. Perhaps, then, there’s a real need to collectively change our everyday language so that we don’t use words and phrases that seemingly make light of mental health problems.

14. Becoming angry more easily than usual

Naturally, anger in itself does not automatically equal depression; in many cases, it’s a natural human reaction to trying circumstances. However, if a person who usually remains unruffled now seems to have a very short temper, this is a more serious sign that something may be awry.

You see, a 1998 study revealed that 33 percent or so of the depression sufferers surveyed have displayed sudden outbursts of rage. And lashing out at a loved one – especially if this is out of character – can be an indication that someone is struggling with their mental health and so needs assistance.

13. A preoccupation with death

Having a preoccupation with death may sound like a cliché when it comes to someone who is acutely feeling the effects of depression, but such a fixation should be taken seriously. Nonetheless, a distinction has to be made between a fascination with death as a finite act and a more morose focus on that person’s own passing – particularly if it involves suicide.

Alarm bells should start to ring, then, if someone you know begins to talk openly about their own death and its potential impact. This could be a suggestion of suicidal ideation, which is typically a symptom of either major depression or bipolar disorder, and so intervention is key before such thoughts turn into real action.

12. Being more pessimistic than usual

Some people are naturally glass-half-empty types, and that by itself may not be cause for concern. It takes all sorts to make a world, after all. However, someone suffering from depression may have begun to ruminate on their own perceived lack of self-worth – especially when it concerns their own abilities.

And noted psychiatrist Mark Goulston advises against getting trapped in such a cycle. He told WebMD, “If you race ahead and anticipate a negative result, which then causes you to stop trying at all, that is something that will rapidly accelerate your depression and deepen it.” So, if someone is pessimistic about upcoming events, it’s worth reinforcing the fact that the future hasn’t yet been decided.

11. Binge eating

As may be the case with alcohol or drugs, a person with depression can seek comfort in food – perhaps through treats that deliver a temporary sugar high, for instance. That said, it can be difficult to determine whether spells of binge eating are leading to feelings of depression or the other way around.

In any event, the University of North Carolina at Chapel Hill’s Cynthia Bulik – who jointly founded the college’s Center of Excellence for Eating Disorders – suggests that there may be a genetic link between binge eating and depression. As a consequence, then, people who experience one of these conditions could be at risk of succumbing to the other.

10. Lack of motivation

Along with trouble sleeping, a lack of motivation is another way in which depression can affect behavior. And the two symptoms may on occasion be linked; after all, if you are perennially tired, your drive is likely to dip. Sometimes, though, a sufferer can be wrongly pegged as being lazy.

Yet laziness may not be the root cause of inactivity in someone experiencing depression. Instead, carrying out even simple tasks may feel beyond a sufferer. So, it’s not that an individual with depression can’t be bothered to take charge; rather, it’s simply not within their capabilities at that time – or so they believe.

9. General disinterest in things that they previously liked

Depression may cause a very real condition called anhedonia, which MedicineNet defines as “the inability to gain pleasure from normally pleasurable experiences.” The site continues, “An anhedonic mother finds no joy from playing with her baby. An anhedonic football fan is not excited when his team wins. An anhedonic teenager feels no pleasure from passing the driving test.”

If someone decides to curtail or even jettison previously cherished hobbies, then, this could be a clear sign of depression. And even if an individual chooses to take part in the same pursuits that they once enjoyed, they may find themselves losing interest – an indicator that they now fail to derive much contentment from these activities.

8. Becoming anxious

There are links between anxiety and depression. In fact, the symptoms of both conditions – not to mention any prescribed treatment – may be one and the same. However, that’s not to say that someone who is suffering from anxiety is always clinically depressed or vice versa. And it’s certainly normal to display feelings of worry in certain situations – before giving a presentation, for instance.

However, in a 2001 article for The Primary Care Companion to the Journal of Clinical Psychiatry, Dr. Robert Hirschfeld emphasized the interrelated nature of the two complaints, writing, “Depressive and anxiety disorders commonly occur together in patients presenting in the primary care setting.” If an individual is inordinately anxious, then, this could very well indicate that they’ve experienced periods of depression, too.

7. Loss of confidence

If a person is experiencing negative thoughts and feelings of anxiety, it’s almost inevitable that a loss of confidence will follow. In a 2018 article published on PsychCentral, Living with Depression author Deborah Serani explained why this may be the case, writing, “Depression often distorts thinking, making a once-confident person feel insecure, negative and self-loathing.”

But owing to that lack of self-esteem, an individual may find it even more difficult to climb out of the depths of depression. Breaking the cycle may therefore require the committed support of family and friends. Finding a method of interrupting dysfunctional thinking patterns – such as cognitive behavioral therapy, for instance – should help, too.

6. A change in character

If a buddy or a relative is behaving in ways that seem out of character, then this could be a sign that they’re in a bad place. Yet it all depends on the ways in which an individual’s personality has transformed, as some changes may actually have arisen as a result of individual growth. With that in mind, then, what exactly should you be looking out for?

Well, as previously mentioned, a depression sufferer may seem more irritable and anxiety-ridden than usual. They may also find themselves leaning on other people more often or becoming somewhat pensive. Fortunately, though, depression doesn’t tend to irreversibly change personality, so treatment may yet bring back the friend or family member you know and love.

5. Suicidal ideation

Sadly, one of the more alarming symptoms of depression is suicidal ideation, as a sufferer could see taking their own life as a way out of the nightmare that they are living through. And while an individual may appear to have everything to live for, depression doesn’t follow any logic. In any case, early intervention is crucial if someone appears to be contemplating suicide.

Such warning signs may include – but are not limited to – bringing suicide into conversation, self-harming, drastic mood swings, taking outrageous risks with physical health and retreating from loved ones. If someone you know exhibits any of these behaviors, then, engage quickly with them and talk things out. Encourage them to seek professional assistance, too, or arrange for this yourself.

4. Lack of productivity

According to research published in 2015 in The Journal of Clinical Psychology, the effects of depression have had a real impact upon the American economy. In particular, the study claims, “The economic burden of depression in the United States – including major depressive disorder, bipolar disorder and dysthymia – was estimated at $83.1 billion in 2000.”

And, of course, that huge sum doesn’t take into account the costs of depression at an individual level. Yet it’s perhaps not surprising that a sufferer may find themselves unable to be as productive as they once were. After all, a person with depression may not only feel lethargic and unable to motivate themselves, but they may also experience physical pain as a result of their condition. With all of that taken into consideration, it stands to reason that productivity may wane.

3. Sleeping too much

As already discussed, there’s a connection between depression and sleep disorders such as insomnia and sleep apnea. By contrast, though, an individual with depression may find themselves with the opposite problem. Instead, they begin to sleep too much – perhaps in part because it’s an easy way in which to shut out negative thoughts.

And as the National Sleep Foundation states on its website, “Altered sleep patterns are a hallmark of many mental health issues.” The organization also suggests, “If you find yourself sleeping too little or too much on a regular basis, it’s important to bring this up with your doctor so the two of you can look at your total physical and mental health picture and decide if further tests or a treatment plan is necessary.”

2. Short-term memory loss

One of the less obvious signs of depression is the condition’s apparent effect on the memory. Yes, according to research, forgetfulness may also be a symptom of deteriorating mental health. A 2013 study carried out by Brigham Young University’s Don J. Shelton and C. Brock Kirwan found, for example, that test subjects with depression were less able to recall having seen certain objects that they had previously witnessed.

That said, memory loss in isolation may be chalked up to something other than depression – whether that’s a brain injury, a lack of vitamin B12 or merely the side effects of medication. Even so, if an individual’s forgetfulness is becoming increasingly common, it’s certainly recommended that they get checked out by a medical professional.

1. Sluggishness

As with many of the signs of depression on this list, sluggishness could be the result of another symptom. Take interrupted sleep, for instance; if an individual doesn’t get those all-important eight hours of rest a night, it’s perhaps no wonder that they feel lethargic. And, indeed, a 2018 report by researchers from Toronto, Canada, claims that 90 percent of those with major depressive disorder have claimed to also suffer from fatigue.

Yet again, though, fatigue can also be caused by any number of physical or medical issues – from an unhealthy diet to more serious conditions such as multiple sclerosis or heart disease. Regardless, if someone is struggling with sluggishness, something may be amiss, meaning intervention of some sort is vital.