When I was first diagnosed with depression, many people—even those who knew me well, who cared about me—responded with the opposite of what I needed to hear. This was partly because they didn’t understand, but also partly because we live in a world where the prevailing view is that mental illness is a weakness and that a person with depression is someone who can’t leave their house, sleeps all the time, lacks enthusiasm, and neglects personal care. Most of the time, this wasn’t me at all. And even when it was, I managed to keep it hidden.
I heard a lot of “You’re the last person I’d imagine to be depressed!” or “But you have so much going for you,” and “How can someone like you have depression?” The cumulative effect of all this unhelpful commentary was mighty. It didn’t stop me from seeking treatment, but it did stop me from talking openly about my illness for over 15 years, because part of me felt that I didn’t deserve help.
I was first diagnosed with depression at 19, and it was another 13 years before a professional gave me a diagnosis of major depressive disorder (MDD). Within just the last few years, the phrase “high-functioning depression” came on my radar. Right away, it was something I could relate to, albeit only with a very literal interpretation: I was a high-functioning person with depression.
Although it’s not new, high-functioning depression has become somewhat of a mental health buzz-phrase—but the exact definition depends on who you ask.
It’s pretty impossible to pinpoint where the phrase high-functioning depression originated. “I don’t think anyone knows,” psychologist Michael E. Silverman, Ph.D., associate clinical professor at the Icahn School of Medicine at Mount Sinai, tells SELF.
But it certainly has merit: “Clinically, depression is characterized as a time of reduced functioning, with the goals of treatment emphasizing symptom reduction,” Silverman explains. “However, this characterization is inadequate, or at least incomplete, when the person demonstrates a level of positive psychosocial functioning that exceeds the average level of non-depressed individuals.”
Depression comes in variations of severity, Silverman says, and it can be difficult to land on one specific diagnosis. “That is, some depressions result in severe disability and hospitalization, whereas other depressions are more akin to the ‘walking wounded,’ [meaning] the individual functions throughout their daily life but isn’t operating as efficiently or productively as they once did or believe they should.” He says a person who might identify as a high-functioning person with depression might describe feeling “as if they are constantly trudging through mud.”
Any discussion of high-functioning depression should acknowledge that this terminology isn’t a recognized clinical disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) or used in research. What’s more, mental health professionals don’t all agree on whether use of the term “high-functioning” in regards to depression is a good or bad thing, or if someone who identifies as having high-functioning depression actually meets the diagnostic criteria for depression at all.
This is because high-functioning depression, depending on how the person using that terminology defines it, doesn’t necessarily require clinical intervention whereas a formal diagnosis like MDD does, Silverman explains. That doesn’t mean a person who identifies as having high-functioning depression couldn’t benefit from seeing a therapist, but MDD is a formal psychiatric disorder for which a professional would prescribe treatment, in the form of therapy and/or medication.
Some experts think that the term high-functioning depression came about due to the lack of clarity around persistent depressive disorder (PDD), or dysthymia, which is a form of depression that is ongoing, but the symptoms may be less severe than those of MDD.
To better understand the many shades of depression, it can be helpful to first think about how all people have a typical baseline mood. “We tend to function close to our baseline at most times and, of course, have fluctuations that are both positive and negative,” Jamie McNally, psychologist and adjunct professor of psychology and owner of Sycamore Counseling Services in Michigan, tells SELF.
Most people have a general understanding of MDD, a mood disorder that interferes with an individual’s ability to function in everyday life. So someone with MDD has a baseline mood that is far below the average individual’s baseline. However, with PDD, the baseline mood for someone with PDD is less clear-cut, falling somewhere between the MDD baseline and a “normal” baseline, McNally explains.
Silverman explains that in the DSM-5, experts essentially collapsed two mood disorders—chronic major depressive disorder and dysthymia—into one: PDD. Before the most recent version of the DSM, PDD was known as dysthymia and used to help identify someone experiencing depressive symptoms for two years or more, but not enough symptoms or with enough severity to classify them as having MDD. (Today PPD and dysthymia are often used interchangably.) When MDD lasts for two or more years, it is typically then classified as chronic. So, while both PDD and chronic major depression both have a duration of two or more years in adults, they differ in severity.
The symptoms for the two disorders are somewhat different and can be confusing, Silverman says. (You can learn more about the very subtle differences here.) He also says that the DSM-5 and the associated diagnoses serve no real utility to the average person or patient, but merely provides a way for clinicians to speak efficiently with each other about an individual’s experience and current level of disability.
“However, in the case of MDD versus PDD, it’s not always efficient or clear,” he says. “For example, if I get a call from a colleague in California seeking assistance with a patient and he tells me Mr. Jones has a diagnosis of PDD, I still don’t know if the patient has dysthymia or if it’s a major depression that’s chronic. Another question becomes, which diagnosis trumps the other? That is, MDD or PDD? This is made even more confusing given that a small group of chronic cases that would meet the criteria for MDD would not meet the criteria for PDD.”
So given that, by the clinical definition, someone diagnosed with PDD in theory has symptoms that don’t necessarily impair their ability to live their life the way symptoms of MDD might, it’s possible that many people with PDD may refer to their situation as high-functioning depression.
But Silverman also points out that the psychiatric concept of “high-functioning” and the clinical characterization of depression both occur on a spectrum. “Whereas a clinical diagnosis of depression has a discrete DSM-5 characterization, the term ‘high-functioning’ has no meaningful clinically utility and is relative to different people across various situations,” he says. “For example, while a professional athlete with PDD is certainly considered ‘high-functioning,’ clinically speaking a person living with schizophrenia who can successfully navigate a typical work day may also be considered ‘high-functioning.’”
Shameka Mitchell Williams, licensed clinical social worker in Baton Rouge, La., tells SELF she believes the term high-functioning depression has also become so frequently used because it takes away some of the ambiguity associated with a label like PDD. “Who wouldn’t rather be considered ‘high-functioning’ even if depressed, versus persistently depressed?” she says. “There is a little less stigma attached if one can still manage to function.”
But it’s the issue of stigma that can also make the concept of high-functioning depression problematic.
Less stigma surrounding those who consider themselves to be high-functioning can mean more blame, judgment, and misunderstanding for those who are not, and it could make people with depression question the legitimacy of their own illness.
“To be high-functioning in some ways acts to trivialize the disability associated with depression that many of these successful patients feel—both internally and with others,” Silverman says. “I’ve had patients say, ‘I’m so unhappy, if I could I’d stay under the covers all day, I feel inadequate and I struggle to think clearly, I’m constantly on the verge of breaking down in tears and I cannot remember a time that I did not feel this way. Yet, I get out of bed every morning, go to work, I can give a presentation, negotiate and close a deal. Thus, I must not really be depressed,’” he goes on. “They often self-diminish the seriousness of their own disorder.”
According to Justine Mastin, licensed therapist and owner of Blue Box Counseling in Minneapolis, people who live with this kind of “hidden” depression can be prone to delaying treatment. “Since others don’t see their suffering, they may receive both implicit and explicit messages that they just need to deal with whatever is happening because it really isn’t that bad,” she tells SELF. “I’ve heard stories from my clients that if they disclose their suffering, they often aren’t taken seriously because they’re able to do all the things that they’re supposed to. The internalized message is that the way they feel is not a concern and that help isn’t warranted.”
But at the same time, because high-functioning depression is colloquial in nature, it can be a less-jargony way for a patient to self-identify or explain their condition or symptoms in a way that makes sense to them. “As a therapist who practices predominantly from a narrative therapy perspective, it’s important to me to use the language of my clients,” Mastin says. “So if a client refers to herself as having ‘high-functioning depression’ then that’s the language we use.
But otherwise, this isn’t a term that she finds to be “clinically useful,” she says. “Like so many aspects of life, an assessment of high-functioning depression is made based on the outside view of a person, rather than on their internal experience.”
Just because high-functioning depression doesn’t have a clinically codified meaning doesn’t mean it isn’t relevant if it helps you understand or communicate your symptoms, as it did in my own experience.
I didn’t actually identify with the term until many, many years after I received a formal diagnosis for major depressive disorder, and only after I started to open up about my diagnosis and treatment.
In my case, the impression I got from non-medical professionals was that I couldn’t possibly be depressed because, well, I was so “normal.” In fact, I was more than high-functioning—I was high-achieving. I was either studying or passing exams or working in a challenging career or running my own business or running marathons. I was getting engaged and pregnant and married and fulfilling all my adult responsibilities. In short, I was doing everything healthy, happy people do—and then some. On the surface, I was winning at life. I was someone to admire, to be proud of. But on the inside, I was struggling big time.
It’s the internal experience that Mastin pointed out that’s so crucial when it comes to getting help. “You shouldn’t get caught up in a definition or diagnosis,” Julie M. Bowen, lead psychotherapist at Hope Therapy and Wellness Center in Springfield, Va., tells SELF. “Treatment for depression looks similar across the board. Clinicians and doctors work with the individual to alleviate the symptoms of depression with therapy and/or medication. The treatment is specific to the symptoms, not the diagnosis. You are not your diagnosis; the diagnosis is just one part of who you are.”
Recognizing this—and truly believing it, which is the hard part—has been a crucial part of my own recovery. Identifying as having high-functioning depression helped me because for so long I bore the burden of an invisible illness, struggling with guilt and uncertainty over whether I actually deserved help.
At the same time, I’m aware that the phrasing may be problematic for some people. But considering its validity and how it can relate to, or overlap, with more “official” diagnoses has helped me. Depression is never one-size-fits-all. I’ve learned that only I can understand my emotions and pinpoint when my personal baseline drops into the danger zone, and that in my daily life, labels—whether they’re officially recognized or not—are immaterial.