Key Takeaways
- The term high-functioning depression isn’t a diagnosis, but most likely refers to persistent depressive disorder or major depression for people whose outward functioning is maintained.
- Depression can cause subtle decreases in functioning that are difficult to identify.
- The severity of depression doesn’t always align with how much a person is struggling.
Introduction
Depression isn’t always visible. Some adults continue meeting their responsibilities while experiencing emotional distress.
Many people think of depression as causing someone to stay in bed all day, call out of work, and cut off from family and friends. While this can happen, not everyone who is depressed acts this way. Depression can look quite different for different people. Adults can suffer from depression while also maintaining successful careers, taking care of families, and functioning in society. For this reason, they (and others around them) may not realize that they’re struggling with depression. This type of depression is often referred to as “high-functioning depression.”
What Is High-Functioning Depression?
The term high-functioning depression isn’t included as a diagnosis in the DSM-5-TR (American Psychiatric Association, 2022) or in ICD-11. Instead, this phrase can refer to several potential types of depression. The term “high-functioning depression” could cause misunderstanding, since someone may assume it means depression that isn’t severe (since the person is “functioning”), when in fact there are already several types of depression that may be diagnosed for someone who fits this description.
High-functioning depression may refer to persistent depressive disorder (also known as dysthymia), although it can also describe people with major depressive disorder who continue to function despite their symptoms. Persistent depressive disorder is when someone has a depressed mood most of the day, more days than not, for at least two years (for children and adolescents, one year is required), as well as two or more of the following symptoms:
- Changes in sleep or appetite
- Low energy
- Low self-esteem
- Difficulty concentrating or making decisions
- Hopelessness
Unlike major depression, persistent depressive disorder symptoms may be less noticeable, and someone may describe it as, “this is just the way I am.” This type of depression is different than cyclical mood changes in response to life events.
High-Functioning Depression Can Still Affect Your Life
Someone with persistent depressive disorder may not realize they’re depressed since the symptoms don’t interfere as noticeably with their ability to function. Someone with this type of depression may continue to go to work every day, take care of the kids, and pay the bills. This can make it harder to realize there’s a problem.
It’s also important to remember that, even though someone may “function,” depression can cause impairment. Some studies have found that most of the cost of depression at work happens when employees are still coming to work, but are not performing to their usual ability (known as the presenteeism effect). Unfortunately, this can be hard to notice for the person and for those around them.
High-Functioning Depression Treatment
Treatment for depression can be effective for people who continue to function despite their symptoms. Depending on the severity of someone’s depression, they may need more treatment (more therapy sessions, combined medication and therapy treatment, etc.) than they expected, especially if the depression has been going on for a while.
High-Functioning Depression May Be Major Depression
High-functioning depression could also refer to major depression (major depressive disorder), since someone could technically meet the criteria for this diagnosis even if they’re still functioning. To meet the criteria for major depression, someone’s symptoms need to cause them distress or impairment. Note that this is distress or impairment, not both! In other words, someone could be in great distress even though they’re still getting everything they need to do accomplished.
Signs of High-Functioning Depression
People who continue to function despite depression symptoms may:
- Still go to work, but feel exhausted all the time
- Still participate in activities, but not enjoy them anymore
- Still accomplish things, but not feel a sense of accomplishment or pride after finishing tasks
- Still go to work every day, but find it increasingly difficult to get through the workday
- Feel exhausted after social engagements and need the rest of the day/evening/weekend to themselves to recover
- Be productive at work, but have hobbies and friendships fall by the wayside
- Feel like they’re on an emotional or mental treadmill that never stops
High-Functioning Depression Causes
There isn’t just one cause of depression. Some risk factors for depression include:
- Family history of depression
- Going through a major life change
- Ongoing stressful situations
- Certain medications and other substances
- Chronic illness or pain
Some people may be more at risk for struggling with depression while still trying to “hold it all together.” For example, someone who:
- Is a people-pleaser or has a hard time saying no
- Is highly responsible or a caretaker
- Is a perfectionist
- Has built up their identity around always being strong, successful, or having it together
It Can Be Difficult to Diagnose Depression in People Who Are Still Functioning
Studies show that depression can be subtle and hard to diagnose. For example, in one study of over 50,000 patients, general practitioners accurately diagnosed depression 47.3% of the time during routine care (Mitchell et al., 2009). Accurately diagnosing depression can be even more challenging for people who are still functioning, since they may not stand out as needing help. If you’re concerned that you (or someone you know) may be depressed, it’s important to mention it to your doctor, so don’t leave it up to chance!
How Common Is High-Functioning Depression?
Research shows that even relatively mild symptoms of depression can cause disability (Judd et al., 2000). In other words, depression doesn’t have to be severe to affect someone’s life. In one study, researchers followed 371 patients with major depression for an average of almost 10 years. During follow-up visits, researchers measured patients’ depressive symptoms as well as any impairment or disability caused by their depression. Disability increased as a function of the level of depressive symptoms, as even symptoms that didn’t meet the criteria for a depressive episode were associated with disability. Impairment due to depression was rare when participants were asymptomatic.
High-Functioning Depression and Productivity
Even when someone with depression is coming to work every day, depression can affect their productivity. In one study of U.S. workers, researchers found that people with depression reported losing an average of 5.6 hours of productivity to health problems each week, compared to the expected 1.5 hours in people without depression. Even more interesting, 81% of the cost was due to presenteeism, which is loss of productivity while still at work, rather than absenteeism or days missed from work (Stewart et al., 2003).
Does Functioning Always Improve When Depression Symptoms Improve?
Not necessarily. In general, depression symptoms and level of functioning don’t always change together (McKnight & Kashdan, 2009). This means that someone could still appear to be functioning well on the outside even though their depression is getting worse, and it could get quite a bit worse before anyone notices. On the bright side, this also means that someone’s depression symptoms could be improving even though it doesn’t yet feel like things are getting better for them. Sticking with treatment is important!
- If you’re having thoughts of suicide or are in crisis, call or text 988 to reach the 988 Suicide and Crisis Lifeline in the United States.
“High-functioning depression” is not an official diagnosis in the DSM-5-TR or ICD-11, but the concept highlights an important clinical reality: depression can occur even in people who appear to be managing well on the outside. For these individuals, depression can be particularly challenging to recognize for themselves and others because it may not prevent them from meeting responsibilities at work, at home, or socially.
Can You Be Depressed and Still Do Well at Work?
Yes. To meet criteria for a mood disorder, symptoms must cause clinically significant distress or impairment. Some individuals who are depressed may be distressed but not impaired. They may also be impaired in ways that aren’t readily apparent to others. Research also shows that a large proportion of the occupational burden of depression is due to poor performance while at work (as opposed to, for example, absenteeism).
If you suspect you may be experiencing depression but continue to function, ask yourself:
- How long have I felt this way? Have I had any periods of feeling well (at least two months at a time) in the last two years?
- Am I functioning because I’m well, or because I’m compensating? What is it costing me (e.g., in my relationships, health, sleep)?
Questions Worth Asking Your Healthcare Provider
If any of that resonates with you, consider discussing your experiences with a primary care clinician or other licensed mental health professional. You might ask:
- Would it be helpful to do some sort of depression screening? Would it be helpful to repeat this over time?
- If I do have a depressive disorder, what would a realistic treatment pathway look like for me, given that my symptoms have been going on for a while? Would psychotherapy, medication or some combination be recommended?
How Is High-Functioning Depression Treated?
For individuals with milder or chronic depressive symptoms, there is evidence to suggest that treatment can be effective. In a meta-analysis of 16 randomized trials of psychotherapy for individuals with chronic major depression or dysthymia, Cuijpers and colleagues (2010) found psychotherapy to be superior to a control condition (although effect sizes were small), and a combination of medication and psychotherapy to be superior to either treatment alone. The researchers also found indications that psychotherapy may be more effective when treatment includes at least 18 sessions, although this does not mean that everyone requires that many sessions. This last point may be particularly relevant for high-functioning individuals, who may expect change to occur over the course of just a few sessions for a problem that may have developed over the course of many years.
Importantly, it may be useful to consider what type of improvement is most meaningful to the individual. When 535 outpatients receiving treatment for depression were asked by Zimmerman and colleagues (2006) about their definition of remission, the items endorsed as “very important” most frequently included the presence of positive mental health (such as self-confidence and optimism), feeling like their usual self, and functioning at their usual level. For those who don’t perceive their level of functioning to have fallen off, treatment goals might emphasize the first two items, feeling like themselves again, not simply continuing to function.
Frequently Asked Questions
Is high-functioning depression a real diagnosis?
No. It’s a term you may hear in everyday conversation, but it isn’t in the official diagnostic manuals used by clinicians (ICD-11 and DSM-5-TR). Many individuals who would be characterized this way likely have symptoms of persistent depressive disorder or major depressive disorder.
Why don’t doctors notice it?
Depression is commonly underdiagnosed in primary care settings, particularly when assessment is limited to a single visit. Conducting depression screening repeatedly over time may improve the accuracy of diagnosis.
How long does treatment take?
This can vary. In cases of chronic depression, research suggests that longer courses of psychotherapy, potentially including 18 or more sessions, may provide additional benefits for some patients. However, treatment duration depends on individual needs and response, and a combination of medication and psychotherapy may be useful.
Final Thoughts
Depression doesn’t always look the way people expect. Someone can have a successful career, maintain relationships, and meet everyday responsibilities while still struggling emotionally. Being able to function doesn’t necessarily mean someone is doing well.
This is what makes high-functioning depression particularly difficult to recognize. People may dismiss their symptoms as stress, exhaustion, or simply part of their personality, especially when they’re accustomed to pushing through difficult situations.
The important thing to remember is that you don’t have to wait until your life starts falling apart to seek help. If you’ve been feeling persistently unhappy, emotionally drained, or disconnected from things you once enjoyed, it’s worth talking to a mental health professional.
Being productive and being mentally healthy aren’t always the same thing. Recognizing that difference can be the first step toward feeling better.
References
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). American Psychiatric Publishing. https://doi.org/10.1176/appi.books.9780890425787
Cuijpers, P., van Straten, A., Schuurmans, J., van Oppen, P., Hollon, S. D., & Andersson, G. (2010). Psychotherapy for chronic major depression and dysthymia: A meta-analysis. Clinical Psychology Review, 30(1), 51–62. https://doi.org/10.1016/j.cpr.2009.09.003
Judd, L. L., Akiskal, H. S., Zeller, P. J., Paulus, M., Leon, A. C., Maser, J. D., Endicott, J., Coryell, W., Kunovac, J. L., Mueller, T. I., Rice, J. P., & Keller, M. B. (2000). Psychosocial disability during the long-term course of unipolar major depressive disorder. Archives of General Psychiatry, 57(4), 375–380. https://doi.org/10.1001/archpsyc.57.4.375
McKnight, P. E., & Kashdan, T. B. (2009). The importance of functional impairment to mental health outcomes: A case for reassessing our goals in depression treatment research. Clinical Psychology Review, 29(3), 243–259. https://doi.org/10.1016/j.cpr.2009.01.005
Mitchell, A. J., Vaze, A., & Rao, S. (2009). Clinical diagnosis of depression in primary care: A meta-analysis. The Lancet, 374(9690), 609–619. https://doi.org/10.1016/S0140-6736(09)60879-5
Stewart, W. F., Ricci, J. A., Chee, E., Hahn, S. R., & Morganstein, D. (2003). Cost of lost productive work time among US workers with depression. JAMA, 289(23), 3135–3144. https://doi.org/10.1001/jama.289.23.3135
Zimmerman, M., McGlinchey, J. B., Posternak, M. A., Friedman, M., Attiullah, N., & Boerescu, D. (2006). How should remission from depression be defined? The depressed patient’s perspective. American Journal of Psychiatry, 163(1), 148–150. https://doi.org/10.1176/appi.ajp.163.1.148
Disclosure: The author is a co-founder of CEREVITY, a private-pay therapy network.
