I began my physical medicine and rehabilitation residency in 1986, during the height of the acquired immunodeficiency syndrome (AIDS) epidemic. Fear shaped every personal interaction. We were still learning how human immunodeficiency virus (HIV) spread, how to protect ourselves, and how to care for patients who were as terrified of the diagnosis as they were of the disease.

Of all the many patients I saw that year, one has particularly stayed with me, even after nearly 40 years. His story continues to remind me how easily emotional suffering hides beneath the surface, and how often we fail to see it.

The hidden weight of a medical diagnosis

He was an army veteran in his 50s, admitted with pneumonia. His medical history was vague, but that was not unusual. As part of the routine workup, an enzyme-linked immunosorbent assay (ELISA) test was ordered. When it returned a positive result, everything around him changed. He was placed in isolation. His family was notified. And he was left alone with a result that, in that era, was likely a death sentence.

During rounds, he pulled me aside. His voice shook as he admitted he had been unfaithful to his wife once, years earlier. He feared that this single mistake would now define him. He was not just afraid of dying; he was afraid of being judged, of hurting the people he loved, of being remembered for something he deeply regretted.

In that moment, I realized he was not just facing a virus, he was facing a scarlet letter. Not one sewn onto fabric, but one etched into his sense of self. Illness, especially stigmatized illness, can brand people with a mark they believe the world will never let them remove. Shame becomes an illness of its own.

I reassured him and reminded him that we still needed the confirmatory test, the Western blot. But fear does not wait for confirmation. It grows in the silence between lab results. It was Christmas. One of the residents gave him a bathrobe as a small holiday gift. He smiled. He thanked us. He seemed lighter, even hopeful. I remember thinking he could be turning a corner.

The next morning, before rounds, we learned he had taken his own life.

The following day, the Western blot test came back negative.

The clinical failure to recognize depression

His death taught me something dramatically that I have seen repeatedly throughout my career: We often miss the underlying suffering that matters most to a patient. And the data show just how common that failure is.

Across multiple studies, physicians miss depression in about half of cases. Meta-analyses and reviews both report sensitivities of roughly 47 percent and specificities of around 81 percent. Recognition is even worse in mild cases, in the elderly, and in patients whose emotional distress presents as physical symptoms.

This is especially concerning because depression is common in primary care. Prevalence ranges from 5 to 13 percent and reaches 14 percent in some cohorts. It is a leading cause of disability and frequently coexists with chronic medical illness, making it even harder to detect. When we miss it, the consequences can be profound. Unrecognized depression leads to worsening symptoms, functional decline, increased health care use, and a higher risk of suicide.

Looking back, that veteran had shared with us his fear. He described his shame. He reached out. We still did not see the depth of his despair, considering it a normal reaction to the diagnosis he had just been given.

Pandemic parallels and the psychology of isolation

Decades later, during the coronavirus disease 2019 (COVID-19) pandemic, I felt echoes of that same emotional landscape. Different virus, different era, but the same isolation, the same stigma, the same fear of being a burden. Once again, patients were separated from their families. Once again, a positive test carried not only medical implications but also moral weight.

And once again, confirmatory testing played a role in shaping fear. During COVID-19, a rapid antigen test often needed confirmation by polymerase chain reaction (PCR), just as an ELISA needed confirmation by Western blot. But patients rarely experience these steps as clinical algorithms. They experience them as verdicts. A preliminary result becomes a psychological sentence long before the final answer arrives.

Both pandemics revealed how quickly uncertainty can erode a person’s sense of identity. During AIDS, patients feared judgment about their morality. During COVID-19, patients feared being blamed for exposing others or not being careful enough. In both eras, people suffered not only from disease but from the stories they believed about themselves.

Moving beyond screening tools to true connection

And clinicians, overwhelmed and stretched thin, often miss the warning signs.

We know what helps increase certainty. Screening tools like the Patient Health Questionnaire-9 (PHQ-9) improve detection, though they are imperfect, prone to false positives and limited by system barriers. They work best when paired with follow-up, treatment, and collaborative care models that integrate mental health expertise. Training, measurement-based care, and system-level support all improve recognition and outcomes.

But tools alone are not enough.

Over the years, I have also lost coworkers to suicide, people I worked with, laughed with, and trusted. I have watched friends bury their children. I have cared for countless patients in the emergency room who attempted to end their lives. Some survived because of timing, some because of luck. Many I never heard about again after my shift ended.

What I have learned is that depression rarely looks like what we expect. Sometimes it looks like a patient thanking you for a Christmas gift. Sometimes it looks like a colleague who seems “a little overwhelmed.” Sometimes it looks like a teenager joking in triage. And at times, it looks like a veteran who smiles politely during rounds.

We are trained to read lab values and imaging, but we are far less comfortable reading fear or shame. We underestimate how a diagnosis, real or suspected, can shake someone’s sense of identity. We forget that a single moment of vulnerability may be the only warning we get.

The AIDS epidemic and the COVID-19 pandemic both taught us that fear can be as dangerous as any virus. Isolation can wound as deeply as infection. And noticing, truly noticing, may be the most powerful intervention we have.

If you or someone you know is experiencing thoughts of suicide or self-harm, early support is essential. Contact a health care professional, reach out to someone you trust, or seek emergency assistance immediately. Suicide is preventable, and timely intervention is a key public health measure to reduce harm.

Francisco M. Torres is an interventional physiatrist specializing in diagnosing and treating patients with spine-related pain syndromes. He is certified by the American Board of Physical Medicine and Rehabilitation and the American Board of Pain Medicine and can be reached at Florida Spine Institute and Wellness. 

Dr. Torres was born in Spain and grew up in Puerto Rico. He graduated from the University of Puerto Rico School of Medicine. Dr. Torres performed his physical medicine and rehabilitation residency at the Veterans Administration Hospital in San Juan before completing a musculoskeletal fellowship at Louisiana State University Medical Center in New Orleans. He served three years as a clinical instructor of medicine and assistant professor at LSU before joining Florida Spine Institute in Clearwater, Florida, where he is the medical director of the Wellness Program.

Dr. Torres is an interventional physiatrist specializing in diagnosing and treating patients with spine-related pain syndromes. He is certified by the American Board of Physical Medicine and Rehabilitation and the American Board of Pain Medicine. He is a prolific writer and primarily interested in preventative medicine. He works with all of his patients to promote overall wellness.