8 Questions About High-Functioning Depression: Expert Answers

Judith Joseph, MD, is a psychiatrist and clinical researcher based in Manhattan, New York. In her new book, High Functioning: Overcome Your Hidden Depression and Reclaim Your Joy, Joseph describes an often overlooked form of depression. Instead of overwhelming sadness and listlessness, people with "high-functioning" depression try to cope through joyless overworking and by giving too much of themselves to others.

Joseph was her own patient zero. In the early days of COVID-19 in 2020, she realized that despite all her professional success – a Trinidadian immigrant with an Ivy League medical degree – she felt miserable. "These folks, myself included, we don't deal with the problem. We just busy ourselves," she says. "And because we get rewarded for our pathological productivity, we don't get the help."

Eventually, she continues, people with high-functioning depression reach a tipping point. They slip into major depressive disorder, have panic attacks, or develop physical symptoms ranging from migraines to vision loss.

Joseph shares how to recognize high-functioning depression, where it comes from, and how to get treatment. 
 

Joseph: High-functioning depression is not yet recognized by the medical coding community, so it's not a diagnosis that you can actually get from a textbook. 

Major depressive disorder, by definition, is a condition where you have the symptoms of depression that are listed in the DSM-V, but at the very end of that list of criteria, you have significant impairment or significant distress. If you have the rest of those symptoms, but in fact you cope by either over-functioning or being productive, you will not meet criteria for major depressive disorder. There's no criteria for you. The same for persistent depressive disorder. 

Burnout is the workplace setting causing fatigue, low motivation, and poor concentration. So when you remove the person from the workplace, they should get better. 

Folks with high-functioning depression, it's different. When they're out of the workplace, they still can't relax. So they're the folks who are out cleaning up their garage, taking on the side hustle, or two – really trying to outrun this problem that they're not even aware exists. 

With the patients we spoke to in our clinical study, they'll say, "I just can't sit still." 
 

Joseph: Anhedonia is a lack of joy, pleasure, or interest in things you once enjoyed. It's been in the medical literature for over 150 years, but most people in the population have never heard of the term.

It's not a crisis, it's not going to get you in the ER. But if you've never heard of anhedonia or your doctor just frankly forgot about it, then you walk around thinking, "Well, that's just life."

And that's not just life. We're supposed to feel joyful. We're supposed to get meaning out of life. Our life is supposed to have purpose and pleasure.

So if we're feeling meh and blah and anhedonic, then we need to work on that.

We have to think about ways to infuse joy back into our lives. Lacking pleasure may not be a crisis, but it is an existential crisis that we can all do better at as individuals.
 

Joseph: My lab found a correlation between trauma and high-functioning depression. This is the only study on this in the world, so we need more studies, but the hypothesis is that people cope with whatever pain or stress or trauma by busying.

Most of the general population thinks that trauma's in one bucket, anxiety's in one bucket, depression's in one bucket. But what we're seeing now with mental health is that a lot of these conditions travel together.

With trauma, one of the symptoms is feeling not good about yourself, internalizing self-blame, and shame. The brain does this to try and control the situation, right? You see this magical thinking, "If I had done X, maybe so-and-so wouldn't have happened." We just internalize these things that happen to us, and we try to make good, we try to outdo them, outrun them.

A lot of the folks that I work with will overwork. They just can't sit still, there’s this inner restlessness.

Joseph: You get rewarded. Everyone on the outside, they think this is wonderful, you're doing well. If you are earning and you are producing, that's considered a measure of success. Whereas you may not even feel internally successful, because you're so depleted and you're actually not getting pleasure from the work anymore.

It's different if you're someone who's productive and you're enjoying your work and you're not experiencing anhedonia. But when you're not deriving a sense of pleasure in life, then that's problematic.

Some of us work hard and we're joyful. We're getting a sense of purpose and pleasure. But others don't. That's when you know that it's a problem. 
 

Joseph: Definitely start with therapy, or at least with an evaluation. That one-on-one individual support is the gold standard, because there's only one you. 

Take the time to understand the signs of your happiness, and work with someone on it. But, say you have high-functioning depression and you then stop functioning – then the antidepressants and the other behavioral treatments are laid out in the book.

Joseph: To be honest, many people don't have access to therapy, or they're on a wait list. So I want people to start accessing what we do know helps with depression: getting out and moving, eating proper foods, tapping into things that bring you joy, purpose, and connection.

People can do these social media detoxes, because when you're on your screens, you're less likely to be engaging in social interactions.  

And the other thing is self-discovery. I talk about being like an archeologist or a historian for yourself, digging back through old pictures, going back in time. Were you someone who used to tinker a lot with your hands? Were you someone who used to craft or bake, and you don't do those things anymore?

Try to understand what it is that excited you, and see if you can go back and do those things again in a small way. 
 

Joseph: I can only extrapolate from what is in the general population. Depression is very, very common. It's one of the most common conditions in the human experience, in terms of mental health. I think anxiety is probably the most common. I wish that I could say that I knew for sure how many people have high-functioning depression, but I don't.

That's why I think we need more screening. We need more help from all practitioners to educate patients about the symptoms and signs of depression. But it's hard to say just how prevalent this is.

Joseph: In the Caribbean, we just don't talk about this. It's more thought of as a spiritual thing. If you have depression or anxiety or anything mental health, then somehow there's a personal defect. Within these cultures, when you come to a new country and you're working hard, you're told everyone goes through this. You're told that you should be lucky to be here, so why are you complaining? That further enforces the idea that you shouldn't talk about what's happening when you struggle.

So what do you do? You just work harder, and eventually people do have breakdowns.

I found that a lot of Asian cultures are similar to what I've experienced, in that you don't really talk about things from a mental health perspective. In the United Kingdom, there’s that stiff upper lip. And in African cultures, many of those folks have gone through so much in terms of war and survival, and they don’t talk about it.

But I think the younger generations are talking about things more openly, and that's a positive thing.