Professor Taiwo James Obindo is a prominent Nigerian professor of psychiatry and a former president of the Association of Psychiatrists in Nigeria (APN). In this interview by Sade Oguntola, he says depression isn’t always about sadness and explains that its warning signs can hide behind success, anger, body pain, and even a smile, and so many people miss this.

When people hear “depression,” they think sadness. What are the most surprising ways clinical depression can actually show up?

Everyone can feel sad, but not everyone who is sad is depressed. Depression is not simply sadness—it’s a disorder that affects mood, thinking, behaviour, and physical health. Someone with depression may present to a doctor complaining of headaches, to an employer because their performance has declined, or to family members because they have become withdrawn or irritable. They may never once say, “I feel depressed.”

For depression to be diagnosed, the low mood must be present most of the day, nearly every day, for at least two weeks. It is also accompanied by generalized body weakness, loss of interest in previously pleasurable activities, and other associated symptoms. Daily functioning must also be impaired.

That is why mental health professionals look at the whole picture—changes in energy, sleep, appetite, concentration, emotions, relationships, and overall functioning—not just whether someone appears sad. Recognising these less obvious signs can lead to earlier diagnosis, earlier treatment, and better outcomes.

Can someone be depressed and still be laughing, working, and “looking fine” on social media? How does that work?

Yes, absolutely. In fact, some of the people with depression who are hardest to identify are those who continue to laugh, work, post on social media, and appear to be doing well. This is often referred to as “smiling depression” or “high-functioning depression.”

Depression affects people differently. Some become unable to get out of bed, while others continue to function because they feel they have no choice. Outward appearances do not always reflect what someone is experiencing internally.

Can someone be depressed if what others notice is that they stop picking up calls, reading messages, or responding to emails?

Yes. Social withdrawal and reduced responsiveness are common, yet often overlooked, signs of depression. In some people, one of the first things family, friends, or colleagues notice is that the person stops answering phone calls, ignores text messages, leaves emails unread, or takes days or even weeks to respond.

This is not necessarily because they do not care. Depression can make even simple tasks feel overwhelming. Fatigue can make responding to a message feel like an enormous effort, while poor concentration makes reading and processing emails or messages difficult. Loss of interest also extends to activities that once felt routine, including social interaction. As a result, people with depression often prefer to be alone and may avoid calls, chats, and emails.

Is it possible for depression to look like laziness, procrastination, or “I just don’t care anymore”?

Yes, it is. A person with depression is often physically and mentally exhausted, and this can easily be mistaken for laziness. Loss of interest and motivation may appear as procrastination because the person keeps postponing tasks they would ordinarily complete.

There is also what we call presenteeism—being physically present at work but performing well below one’s usual standard. This differs from absenteeism, where the individual frequently takes sick leave, finds excuses to miss work, or may even go AWOL.

Some people with depression overeat or oversleep. Others can’t eat or sleep at all. Why are the symptoms so opposite?

That is one of the fascinating—and often confusing—aspects of depression. It is not a single illness that affects everyone in exactly the same way. Presentation is individualized. Depression disrupts multiple brain systems involved in regulating mood, sleep, appetite, energy, and motivation, and those systems can be affected differently from one person to another.

The fact that one person with depression cannot sleep while another sleeps all day does not mean one of them “doesn’t really have depression.” Both may have the same illness expressed in different ways.

That is why depression is diagnosed through a careful clinical assessment rather than a checklist of one or two symptoms. Understanding these variations helps ensure people are not overlooked simply because their depression does not fit the stereotype of someone sad, eating less, and lying awake at night.

The more common presentation includes loss of appetite, insomnia, and weight loss. However, in atypical depression, the individual may overeat—almost as though “soaking” the depression in food—sleep excessively, spend most of the day in bed, and gain weight.

Can depression make someone unusually productive, perfectionistic, or a workaholic? Is that a coping mechanism?

Yes. Some people cope with depression by immersing themselves in work. They are often described as workaholics because work temporarily distracts them from the emotional pain they are experiencing or the source of their stressor. Pleasing others through constant productivity may also become a coping mechanism.

One personality type that is particularly prone to depression is the obsessive-compulsive personality, often described as perfectionistic. Such individuals tend to have rigid patterns of behaviour, insist on doing things in a particular way, and become uncomfortable when routines or expectations change.

What about “smiling depression”? How dangerous is it when someone masks their pain?

“Smiling depression” is a popular term rather than a formal medical diagnosis, but it describes a very real and potentially dangerous situation: someone who appears happy, successful, or emotionally stable on the outside while experiencing significant depressive symptoms internally.

These individuals may continue going to work, attending school, caring for their families, and socialising, so those around them may have no idea they are struggling. One of the greatest dangers is that their condition often goes unnoticed.

Comments such as “You don’t look depressed,””You’re always smiling,””You have so much going for you,” or “You’re the strong one” can make them feel even more isolated and less likely to seek help.

This is why someone who appears cheerful or productive can still be at significant risk. A person’s outward appearance should never be used to judge the severity of their emotional distress. In some cases, people deliberately maintain a cheerful façade to hide suicidal thoughts or plans, leaving relatives and colleagues completely unaware of the danger.

What are the other symptoms to look out for in those who are irritable?

Yes. Depression can present with irritability rather than obvious sadness, particularly in some individuals. Other symptoms include changes in appetite, disturbed sleep, reduced libido, low self-esteem, excessive fear, and irrational guilt, where the person repeatedly begs for forgiveness without a clear reason.

In severe depression, people may experience hallucinations—for example, hearing voices that accuse, ridicule, or even instruct them to harm themselves. Some may also become suspicious or develop false beliefs about others causing them harm.

Can depression cause physical pain—headaches, body aches, stomach issues—even when there’s no medical cause?

Yes. Depression can present with physical symptoms, particularly in African populations, where emotional distress is often expressed through bodily complaints—a phenomenon we refer to as somatisation.

People may complain of unexplained body pains, a feeling of internal heat, heaviness of the head, a tight band-like sensation around the head, peppery sensations, or crawling feelings under the skin, even when no underlying medical cause is found.

How does depression manifest differently in men versus women? I hear men become more angry and engage in risk-taking.

The differences are generally not dramatic. Women are more likely to experience crying spells because of their low mood, while men may express depression through irritability, anger, or increased risk-taking behaviour.

I once managed a senior matron who, whenever she became depressed, drove recklessly. The important point is that depression itself is not fundamentally different between men and women. However, biology, social expectations, and coping styles can influence how symptoms are expressed and recognised.

Recognising these different patterns helps families and healthcare providers identify depression earlier and connect people with appropriate treatment.

In children and teenagers, can depression look like tantrums, school failure, or “bad behaviour” instead of sadness?

Yes. In children and adolescents, depression often does not resemble the typical sadness seen in adults. Instead, it may present as irritability, behavioural problems, declining academic performance, or recurrent physical complaints. As a result, it is frequently mistaken for laziness, disobedience, or simply “bad behaviour.”

Declining school performance may be one of the earliest signs. School refusal, absent-mindedness in class, tantrums, and other regressive behaviours may also occur.

Some adolescents become withdrawn and isolated, while others become argumentative, defiant, or aggressive. Unfortunately, these behaviours are often dismissed as “just adolescence,” attention-seeking, stubbornness, or a need for stricter discipline.

What treatment options work best when the main symptoms are physical pain, anger, or numbness instead of sadness?

Psychotherapy, together with careful social assessment, may be particularly helpful. Although depression may present as physical pain, anger, or emotional numbness rather than sadness, the core treatment principles remain the same. The approach is simply tailored Towards addressing the underlying psychosocial issues identified as the stressor(s)

The first and most important step is making the correct diagnosis because many people with these symptoms do not realise they are depressed. They may spend months—or even years—seeing orthopaedic specialists for pain, using alcohol to cope with irritability, or assuming they have simply become “cold” or “burnt out.”

Recognising these symptoms as manifestations of depression allows people to receive appropriate treatment sooner, improving not only their mood but also their physical health, relationships, and overall quality of life.

Why does the brain produce such different symptoms for the same illness? What’s happening biologically?

The brain responds differently to environmental stressors in different individuals. We understand mental illness as resulting from the interaction between nature—our genetic predisposition—and nurture, or our environment.

Because people’s genetic makeup and life experiences differ, the factors that precipitate depression also differ. Likewise, the level of resilience in individuals also differs. Consequently, the way depression presents—and the approach to treatment—can vary from one individual to another.

Because symptoms are so varied, how often is clinical depression missed or misdiagnosed?

For a psychiatrist, rarely. However, in busy general outpatient clinics, depression is often missed because many patients present primarily with physical symptoms. Limited consultation time may not allow healthcare providers to explore psychological symptoms in sufficient detail.

As a result, the same individual may return repeatedly with unresolved complaints before the correct diagnosis is finally made, placing further strain on an already overstretched healthcare system.

What’s the one sign that should make someone say, “I need to see a psychiatrist,” even if they don’t feel sad?

There is rarely a single symptom in the early stages. Rather, it is a constellation of symptoms, including persistent low mood, fatigue, loss of interest in previously enjoyable activities, or more severe symptoms such as suicidal thoughts, hallucinations, or delusions of guilt—for example, repeatedly begging for forgiveness without a rational basis.

The important message is that psychiatrists treat far more than sadness. They assess disorders affecting mood, anxiety, sleep, thinking, behaviour, and substance use, while also considering medical conditions that can produce similar symptoms.

If changes in your emotional or mental state are persistent, cause distress, or interfere with your daily functioning, it is time to seek professional help—even if you never describe yourself as “depressed.” Early assessment often leads to earlier treatment and better outcomes.

What’s the biggest myth about depression in Nigeria that’s preventing people from getting help?

One of the biggest myths is that depression is caused by a lack of faith, spiritual attack, or “people from the village,” rather than being a medical condition.

A person in many Western countries may comfortably say, “Doctor, I think I’m depressed. I’ve not been happy for the past two weeks, and I need help.” In contrast, many Nigerians remain in denial because of the stigma associated with mental illness.

Some people also believe treatment is ineffective or that antidepressants are addictive. Limited mental health education, a shortage of trained mental health professionals, and inadequate integration of mental health services into primary healthcare all contribute to delayed diagnosis and treatment.

In Nigeria, many people express emotional pain through spiritual language, saying, “I’m under attack.” How do you distinguish that from clinical depression? And how do you distinguish it from substance use or medical conditions that mimic depression?

A detailed clinical history, physical examination, and appropriate investigations usually help make the distinction. The key point is that clinical depression is diagnosed based on a characteristic pattern of symptoms and impairment, not on the language people use to describe their experiences.

Someone who says they are “under spiritual attack” may still have major depressive disorder if, for at least two weeks, they have experienced persistent sadness or emptiness, fatigue, changes in sleep or appetite, loss of interest or pleasure, and recurrent thoughts of death or suicide. What people termed ‘spiritual attack’ are actually the manifestations of the depression, e.g.,someone not sleeping well or having nightmares may attribute these to spiritual attack. Lack of motivation may be interpreted as the “devil hindering them from progressing”. Also, seeing or hearing things not experienced by others around (which we call hallucination) is a fertile ground for assuming it is a spiritual attack.

The clinician explores whether the spiritual explanation represents the person’s interpretation of their suffering while simultaneously assessing whether they meet the diagnostic criteria for depression.

For example, someone may believe spiritual forces are responsible for their persistent sadness, insomnia, and hopelessness. That belief, in itself, is not evidence of mental illness. What matters clinically is the presence, severity, duration, and functional impact of the depressive symptoms.

If the person’s beliefs are consistent with those commonly held within their cultural or religious community and they remain grounded in reality, they are not considered delusions simply because they involve spiritual explanations.

Several medical conditions can also mimic depression, including anaemia, diabetes, thyroid disorders, chronic pain conditions, and certain substance use disorders. These possibilities should always be considered, especially when symptoms are new, severe, or accompanied by other physical signs. (Nigerian Tribune)