‘High-functioning depression’: What does it mean and symptoms to look for

Jennifer E. Engen

“High-functioning depression” is not a clinical diagnosis found in the Diagnostic and Statistical Manual of Mental Disorders (DSM), a handbook used by health-care professionals. It’s a colloquial term that has grown in popularity in recent years, although some experts have mixed feelings about its use.

The phrase highlights “a really important point that people can be suffering with mental illness and still appear outwardly to be able to function or not appear mentally ill to an outside observer,” said Rebecca Brendel, president-elect of the American Psychiatric Association.

But, Brendel added, the term could exacerbate shame and misunderstanding about mental health and depression. “Saying that somebody is high-functioning even though they have a mental illness in and of itself raises the stigma associated with mental illness.”

Here’s what some mental health experts think about this increasingly common phrase.

What is ‘high-functioning depression’ and why can the term be helpful?

Broadly, “high-functioning depression” is a nonmedical term that can be used to describe certain people who meet the criteria for a clinical diagnosis of depression, but manage to function day-to-day in a way that their mental condition probably isn’t apparent to others or even to themselves, said Jameca Woody Cooper, a psychologist and adjunct professor at Webster University in Missouri.

And although “high-functioning” can be associated with “high-powered” individuals or public figures, that isn’t always the case, Woody Cooper said.

“It can be a teacher, it can be a person who works at a day-care center, it can be a fast-food worker,” she said. “Everyone from all walks of life can experience major depression, and everyone from all walks of life can look like or present like a person with high-functioning depression.”

Clinical depression is diagnosed along a spectrum that takes a person’s ability to function into account. But the phrase “high-functioning depression” can be enlightening for those with and without depression.

People often “carry this image of individuals who are crying, who are stuck in bed, who are suicidal,” Woody Cooper said. “When in fact, it actually looks totally different in people who are functioning every day.”

Montrella Cowan, a relationship therapist, speaker and author based in Washington, D.C., agreed. Understanding “high-functioning depression” can help raise public awareness that it’s possible for a person “to be productive, make six figures, have the biggest house, a nice car, and be depressed,” she said.

It can also help someone know they are not alone, Cowan said, because “a lot of times people aren’t feeling like themselves and they just can’t put their finger on it, and they just suffer in silence. But now it’s like, ‘Oh, high-functioning. Okay, so no wonder I get up and go to work.’ ”

What are some concerns about the term?

The term can reinforce shame about depression, said Natalie Dattilo, a clinical psychologist with Brigham and Women’s Hospital in Boston. “Stigma is the reason why we use that term to qualify it, [as if] it’s so shocking that successful people can have depression.” But, she added, “it shouldn’t be so shocking that people have depression. That should just be a thing, like people can have medical illnesses.”

Another concern, Woody Cooper said, is that using the term “high-functioning” might be incorrectly interpreted as a less serious form of depression.

“Depression is depression,” she said. “Just because some people have personality traits that make them more able to function shouldn’t make them less likely to be taken seriously, and I’m afraid that’s what can happen if we start to really see this term ‘high-functioning depression’ used even more.”

Additionally, using “high-functioning” as a descriptor can be misleading, said Matthew Rudorfer, program chief at the National Institute of Mental Health, because it doesn’t take into account the effort it takes to function.

“If every car on Connecticut Avenue is driving along at 35 miles an hour, but one driver has to push the gas pedal to the floor to maintain that, to the outside observer all seems well,” he said. “But they’re trying too hard. It shouldn’t take flooring the pedal to go 35 miles an hour.”

Should we even use the phrase ‘high-functioning depression’?

Experts have differing opinions about whether “high-functioning depression” should be a widely used mental health term or become an official diagnosis.

“The best thing we could do is get away from labels altogether,” Brendel said, because they can “really get in the way of understanding what’s happening with mental illness.” Instead, she encouraged open conversations “about the symptoms of mental distress” and working toward reducing stigma and other barriers to getting care.

Cowan, however, said the benefits of using the phrase “high-functioning depression” may outweigh the potential downsides and noted that she believes the term should be included in the next update to the DSM. (To date, no proposals have been submitted to include “high-functioning depression” in the DSM, according to the American Psychiatric Association.)

“We’re trying to normalize the conversation,” Cowan said. “If we start to say, ‘You can’t use this term, you can’t use that term,’ now we won’t have much to talk about.”

Although she has concerns about it, Dattilo said she’s okay with the term if it can enable someone to get help. “If this is the thing that allows them to look and say, ‘Oh, maybe that’s what I have,’ then let’s go ahead and use it and continue to work toward something better.”

It’s important, experts said, to recognize who might be at risk for experiencing this type of depression.

Woody Cooper said she often sees it in people with “Type-A personalities.” Other characteristics may include holding an important position, struggling with perfectionism, being a people-pleaser or wanting to be perceived as strong and capable, Dattilo said.

“None of those are bad qualities, but those can also factor into a person’s system of beliefs about themselves,” Dattilo said. All of which “can contribute to the pressure to perform and to be a certain way and to have certain things.”

Woody Cooper and Cowan also noted that “high-functioning depression” is often observed in communities of color, where barriers to getting treatment can be higher due to cost, availability and cultural stigma. “In the Black community, for example, we’re still trying to fight this stigma about ‘You are weak,’ ” Cowan said. “As if we’re weak if we reach out for help — and that’s not true.”

The barriers to seeking help may be greater for Black women, Woody Cooper added. “They have this kind of image as superwomen, that they can do everything but yet not feel anything,” she said.

What are some signs of high-functioning depression?

It can be difficult to spot signs of depression in people who might not recognize it in themselves or who might be actively masking their symptoms and pushing through, perhaps because appearing outwardly strong and capable is integral to their identity, experts said.

Brendel said people who are worried about possible depression in themselves or others should watch for subtle changes, including shifts in energy, mood and quality of sleep. Those changes could just be a signal that someone needs to reset and prioritize taking care of themselves, she said. But, she noted, if they persist over a two-week period, it may be a sign to seek professional help. Other potentially concerning signs are bleak thoughts about the future, as well as feelings of hopelessness and powerlessness.

If you’re trying to support someone else, avoid making assumptions. Don’t, for instance, tell a person they need therapy, Cowan said.

Woody Cooper suggested asking questions first and framing potentially concerning behavior changes as things you’ve noticed. For example, you could say, “I’ve noticed that when we’re out with the group lately, you’re not talking as much,” Woody Cooper said, and follow up with questions such as, “Is everything okay? Is there anything you want to talk about?”

Experts recommended having a referral to a mental health professional ready. It may also help if you’re able to share personal experiences of seeking mental health support.

“Admitting or acknowledging that you’re struggling and that you need help is not an easy thing to do,” Dattilo said. That’s why experts believe one of the most important takeaways from discussions about “high-functioning depression” is the need for conversations, education and attitudes about depression and mental health to continue to change.

https://www.washingtonpost.com/wellness/2022/02/17/high-functioning-depression-meaning-symptoms/

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