High-Functioning Depression

Depression can be a disabling and overwhelming disease that makes even basic functioning difficult. But there is one variety of depression that does not produce debilitating symptoms, or clear indications that something is terribly wrong.

This is called high-functioning depression, although it is also known by two other names: persistent depressive disorder (PDD) and dysthymic disorder. High-functioning depression produces low-grade depressive symptoms that can last for years, unlike episodes of major depression which tend to recede in 6-12 months.

On the outside, people suffering from this condition don’t display many signs of a mood disorder. For the most part they are able to work, maintain their households, manage interpersonal relationships, handle parental responsibilities, and seemingly enjoy their lives to at least some extent.

But with high-functioning depression, external appearances are deceptive. On the inside, individuals dealing with chronic, low-level depression feel empty and unmotivated. They manage to put on a good show, but they feel physically, emotionally, and spiritually drained by the burden of living an unsatisfying and inauthentic existence.

Their depression is every bit as real as the depression of a person diagnosed with major depression, but because the symptoms manifest in muted form they do not cause the same level of disruption or emotional pain. Even if someone with high-functioning depression opens up to loved ones or therapists, they may seem unhappy rather than depressed, and it may not be clear what is really going on.

While it is not a disabling disorder, high-functioning depression has consequences. It can prevent sufferers from reaching their full potential as students, employees, friends, creators, partners, and citizens, and it severely limits their ability to find enjoyment and fulfillment in their achievements.

In comparison to major depression, high-functioning depression is relatively unknown. But mental health researchers have been studying the disorder extensively for more than two decades, and they have uncovered a wealth of revealing data about this underpublicized mental health condition:

• The 12-month incidence rate for high-functioning depression among American adults is 1.5 percent, which equals approximately 3.5 million people.
• The lifetime incidence rate of high-functioning depression for American adults is 3.6 percent.
• Adults experience the symptoms of high-functioning depression for an average of five years, while one- to two-year periods are typical for adolescents and children.
• In the United States, 49.7 percent of all diagnosed cases of high-functioning depression can be classified as “severe.”
• High-functioning depression strikes at all ages, but people in the 45-59 age group have the highest 12-month rates of high-functioning depression (3.7 percent).
• Only 61.7 percent of people experiencing high-functioning depression symptoms will receive clinical treatment.
• About three-quarters of sufferers will experience the episodes of major depression as well, either before, during, or after their encounters with high-functioning depression.
• High-functioning depression is frequently accompanied by co-occurring mental health disorders, including major depression (75 percent incident rate), anxiety disorders (50 percent), personality disorders (20-40 percent), and substance use disorders (50 percent).

Despite differences in duration and intensity, the symptoms of high-functioning depression closely resemble the symptoms of major depression. They include:

• Inability to experience true joy
• Chronic low energy
• Constant feelings of self-doubt
• Negative self-evaluations and frequent self-criticism
• Persistent feelings of guilt and shame
• Changes in eating habits (overeating or loss of appetite)
• Changes in sleeping patterns (insomnia or sleeping too much)
• Feeling of pessimism and hopelessness
• Chronic irritability
• Trouble with focus and concentration
• Declines in productivity, in every area of life
• Indecisiveness, frequent changes of jobs, relationships, or life plans

With major depression, symptoms such as these are often obvious to others, and it is clear to friends, family members, and co-workers that something is seriously wrong. But people suffering from low-grade depression are good at hiding their feelings from others, and for the most part their words and actions don’t reveal the depth of their angst.

High-functioning depression symptoms emerge from a combination of influences. The specific risk factors for high-functioning depression include:

• Family history. Having a close family relative (parent, sibling, child) with a mood disorder increases the chances of developing high-functioning depression.
• Negative personality traits. People with low self-esteem, perfectionist tendencies, and a negative outlook on life in general are more inclined to experience the symptoms of depression.
• Trauma and high stress. Physical, emotional or sexual abuse, the loss of a loved one, financial setbacks, relationship troubles, and other stressful or traumatic experiences can contribute to the onset of depressive disorders.
• Co-occurring mental health disorders. High-functioning depression seldom appears in isolation but instead manifests in combination with other mental or behavioral health issues.

While people with high-functioning depression may seem healthier than individuals with major depression, their persistent emotional and psychological symptoms still limit them in a number of ways.

Complications abound for men and women with high-functioning depression. Their misery may be veiled most of the time, but their condition has real-life effects that can plague sufferers who never receive treatment.

Some of the consequences of high-functioning depression may include:

• Family conflicts and relationship problems
• Difficulty holding jobs or maintaining good grades in school
• Drug and alcohol abuse
• Chronic pain and physical illness
• Preoccupation with suicide, or actual suicide attempts

People with high-functioning depression are hard on themselves, and that helps push them forward and keep them moving and achieving despite their inner discontent.

Eventually, however, their lack of self-confidence and enthusiasm for living will have a noticeable impact on their behavior. When they start having—or causing—problems, their loved ones are usually surprised by the sudden changes. But those changes were predictable and inevitable, and when they occur it should be seen as a cry for help.

The subtlety of its symptoms makes high-functioning depression a difficult disorder to detect, even for trained mental health professionals. Another complication is that people suffering the symptoms of high-functioning depression often don’t think of asking for help, and their family members don’t notice the warning signs of trouble, either.

But the good news is that when people with high-functioning depression report their symptoms honestly and completely to physicians or mental health professionals, their condition should be relatively easy to recognize, assuming the clinician has some experience with the disorder.

Under standards established by the Diagnostic and Statistical Manual of Mental Disorders (DSM 5), to receive an official diagnosis for high-functioning depression, persistent depressive disorder, or dysthymic disorder (different practitioners may prefer different terms), patients must:

1. Have experienced low-grade depression symptoms for at least two years (one year in children and adolescents)
2. Have had no symptom-free periods lasting two months or longer
3. Show signs of at least two of the following symptoms:
   • Disruptions in appetite or eating patterns
   • Poor sleep or excessive sleep
   • Low self-esteem
   • Excessive irritability (this is a defining characteristic in children and teens)
   • Concentration problems
   • Trouble making decisions
   • Feelings of hopelessness, defeatism, and despair

Serious manifestations of these symptoms could be a sign of major depression. But if the patient is continuing to handle home, family, and employment responsibilities successfully despite their inner turmoil, high-functioning depression is the appropriate diagnosis.

Too often, people suffering from high-functioning depression just assume that’s the way life is. They try to cope with their symptoms as best they can, but it never occurs to them to try anything else. They are often accustomed to just working harder to overcome other challenges in their lives.

But coping is only the first step on the road to healing from depression, and it shouldn’t become a permanent lifestyle choice. High-functioning depression sufferers who seek professional help can expect considerable improvement in their conditions over time, and they may be able to achieve long-term symptom-free status if they remain diligent and attentive during their recovery.

Treatment programs for high-functioning depression will likely include a combination of psychotherapy and medication, although some sufferers do better with a treatment plan that emphasizes one over the other.

Complementary mind-body healing techniques like meditation, yoga, Tai Chi, massage therapy, acupuncture, and biofeedback can also support improved mood and functioning in most depression patients, who benefit from practices that promote mindfulness and better approaches to stress management.

Even though antidepressant medications are designed for use in the treatment of major depression, they generally work just as well for people diagnosed with high-functioning depression. Long-term therapy is highly advantageous for anyone recovering from depression, since it can help them preserve a positive mindset and reinforce the behavioral strategies that support health and healing.

Most treatment for high-functioning depression will take place on an outpatient basis. But seeking targeted therapy at a residential treatment center can work wonders for those who’ve suffered the symptoms of high-functioning depression for an extended period of time. This is especially important if co-occurring emotional and behavioral health disorders have been diagnosed, as they frequently are in people with depressive conditions.

Inpatient treatment programs can help people with high-functioning depression gain a good understanding of their illness, while developing the core skills necessary to manage their depression symptoms and remain engaged in their continuing recovery program.

Intensive inpatient treatment won’t last indefinitely, but the insights gained by high-functioning depression sufferers who choose this option will stay with them for a lifetime.

At Bridges to Recovery, we specialize in diagnosing and treating complex psychiatric and emotional issues such as high-functioning depression. We provide compassionate and effective care in a serene residential setting so clients can focus on their treatment and recovery without the worries of external pressures and stressors.

• Private residential accommodations. Our exclusive residential treatment homes have a maximum of six clients, providing a safe, private alternative to a more traditional hospital environment.
• World-class clinical staff. Our expert clinical team provides individual therapy using proven evidence-based treatment modalities to treat high-functioning depression.
• Individualized treatment plans. After a thorough assessment, we create a truly individualized treatment plan that offers profound healing and strategies for overcoming the toughest obstacles.
• Health and wellness focused. To ensure your comfort during your healing process, our chefs create delicious healthy, gourmet meals. We also offer yoga, meditation, acupuncture, massage, and physical fitness classes.

At Bridges to Recovery, we believe that exceptional psychiatric, clinical, and holistic care can transform lives. With the utmost dignity and respect, we meet you where you are to develop a vision for the life you wish to have, and offer the care you need to achieve it.