A few years ago, clinical psychologist Margaret Rutherford received an email from a grieving widow, looking for answers. Throughout their lives together, her husband showed no signs of depression other than needing a few drinks at night to relax. Then, one day, out of nowhere, he drove to the edge of their multi-acre property and hung himself.
This is the type of patient Rutherford worries about when she hears the term “high-functioning depression,” and why she thinks it should change — i.e., it falsely implies that they’re doing fine. “Because our profession is stuck on using the traditional criteria for depression, we miss it,” Rutherford warns. “We don’t ask the right questions.”
Although there is little scientific data on the suicide risk of those with high-functioning depression, marriage and family therapist Saba Lurie has observed a similar phenomenon. “Many individuals who suffered from high-functioning depression and died by suicide were often not considered by those who knew them to be depressed,” Lurie tells me. That’s why Rutherford prefers the term “Perfectly Hidden Depression,” because it underscores the covert nature of the affliction.
Whatever you call it, though, high-functioning depression isn’t a technical diagnosis. The correct name, according to the DSM, is persistent depressive disorder (PDD), or formerly, dysthymia. Unfortunately, many people with high-functioning depression won’t find that all their symptoms match PDD either, which includes many of the same symptoms as major depressive disorder, like low self-esteem and feelings of hopelessness.
Either way, Rutherford and Lurie agree that the “high-functioning” part of this type of depression is only possible when you’re aware of the following hidden signs…
Plagued by Perfectionism
People with high-functioning depression tend to struggle with what Rutherford describes as “socially prescribed perfectionism,” or perfectionism that’s mostly about validation from external sources. On the surface, it seems like they have everything going for them, but really, that perfectionism frequently stems from low self-esteem.
“You’re constantly meeting the expectations of others and you must do it perfectly,” Rutherford explains. That’s the difference between people who are successful and people who are perfectionists. People who are more internally motivated to succeed know when to stop. But these kinds of perfectionists never stop because there’s always someone else to impress or please. For them, it might feel like “you’re on a treadmill but you have no control over the incline or speed,” Rutherford says.
Doing Too Much
When perfectionism isn’t satisfying enough for someone with high-functioning depression, they put more on their plates to make up for it. “You’re constantly adding one more task and one more task until your life simply becomes a series of things to get done,” Rutherford says.
Much like perfectionism, the need to take on too much is rooted in avoidance. People with high-functioning depression will do anything to get out of feeling deeper, darker and more painful emotions. All of this adds up to what Rutherford describes as “‘concrete camouflage,’ because it hides what you don’t want anyone to see and don’t want to admit to yourself. But it becomes heavier and heavier with time.”
Engaging in Extreme Compartmentalization
Rutherford likes to think of compartmentalizing as an adaptive trait people develop in order to get things done, where we put unwanted emotions into a box to deal with later. “When something is too severe, it will be put away,” Rutherford explains. The difference is that people with high-functioning depression rarely open those boxes back up. As such, the pile accumulates, and it can start to feel insurmountable. “Compartmentalization in and of itself is a skill, but when it’s overused to avoid or deny pain, that’s when it becomes a problem,” Rutherford says.
Using Gratitude Against Yourself
People with high-functioning depression tend to project a positive, “count your blessings” attitude to the world, but that’s often because they use such an outlook as a way to dismiss internal cues that something is wrong. Many people think they can’t be depressed because they have a good job, a nice house or anything else that can be jotted down in a gratitude journal.
Projecting your #blessedlife to the world isn’t always a bad thing, but when it becomes a way to avoid emotional pain, it’s another way to compartmentalize and not deal with real feelings.
Grappling With Masculine Norms
Although there are plenty of women who deal with high-functioning depression, the tendency to bury emotions and overcompensate with achievements is something that’s more socially conditioned in men. This may make them more susceptible to what the American Psychological Association refers to as “covert depression,” the prevalence of which remains unknown because it’s so underdiagnosed.
This partially explains the paradox of why depression rates for men are about half of women, and yet, men are four times more likely to die by suicide. As Rutherford puts it, “We have these stereotypes about what it means to be a man — not sad, weak or depressed. Men get so adept at hiding these things that they become concealed to themselves. It’s one of the ways they can make sure they don’t appear sad, weak or depressed.”
Thinking Depression Can Only Look a Certain Way
Just as there are plenty of masculine stereotypes, there are countless tropes on what it means to be depressed — a teary-eyed person in pajama pants looking out the window while it’s raining, for instance. People with high-functioning depression can be more likely to buy into this stereotype, and use it as a means of keeping their depression hidden from themselves.
“There are all of these outward markers of success that they possess — productivity, accomplishments, ability to make it through busy days — that can make it difficult for them to recognize the extent of their depression,” Lurie tells me. Which is why she believes it’s better to think of depression as existing on a continuum, where “people aren’t either necessarily high-functioning or low-functioning, but may find themselves on different parts of the spectrum at different times.”
An Inexplicable Feeling That Something Is Wrong
Since many people with high-functioning depression don’t consider themselves depressed, it continues to be difficult to diagnose and treat, even when those people are in therapy. “I have clients who often express complete denial of their depression because of how otherwise full their life is. But when pressed, they can’t explain why they sometimes struggle to engage with others, have periods of time where it’s hard to get out of bed or wish they wouldn’t have gotten up in the morning,” Lurie says.
To Rutherford, these are the people who know deep down that something is wrong. The thing is, because of all the accomplishments and toxic positivity others see on the surface, when they finally get to a point where they can’t contain their feelings and ask for help, it’s much easier for family and friends to dismiss them. “Even when they take one tiny baby step to let someone know what could be wrong, they get shut down,” Rutherford says.
That’s why it’s not enough for clinicians like Rutherford and Lurie to understand the subtleties and nuances of high-functioning depression. We all have to broaden our idea of what depression looks like. “It’s so vital that we make time to check in on our friends and loved ones, especially the ones who seem okay,” Lurie warns.
If anything, it might be the ones who seem the most okay that we need to check in on the most.