High functioning depression: why you feel flat, what helps

Is high functioning depression a real condition?

High functioning depression is a real experience with an unofficial name. The Cleveland Clinic states that it is no formal diagnosis.

• Depression itself. The World Health Organization describes a depressive episode as lasting most of the day, nearly every day, for at least 2 weeks.
• No output test. Nothing in that definition says anything about how much you still achieve.
• The long form. Persistent depressive disorder, once called dysthymia, describes depression that has lasted at least 2 years, the threshold used in a German population study.
• The nearer fit. That is the closer description for somebody who has felt like this for as long as they remember.

Why does nobody notice high functioning depression?

People look for a drop in output, and output is the last thing to go. Depression is recognised by visible consequences: missed work, cancelled plans, a life that stops.

• Colleagues. They see the work.
• Friends. They see you turning up.
• You. You alone know what it costs, and you have spent a long time becoming unreliable on that question.
• The heavier burden. The German study found people with the persistent form worse off than people with shorter episodes on quality of life and on limits to daily activity.
• Missed at scale. The WHO reports that in high-income countries only about one third of people with depression receive mental health treatment.
• Abroad. Move country and nobody around you holds a picture of how you used to be.

Read more about struggling in silence.

What is the functioning protecting?

The functioning does a job, and you need to know the job before you put it down. This is my clinical view.

• An identity. If you have been the reliable one since childhood, a missed deadline changes who you are.
• Other people. Somebody has to keep the household running, and you have decided it is you.
• Not finding out. As long as you still produce, the question of how bad this is stays unanswered.
• The good hours. Work gets them because work has witnesses. The evening gets whatever is left.
• At home. The people who love you get the version already spent, and they read it as being shut out.

Read more about feeling disconnected from your partner.

How is this different from a low patch?

A low patch lifts, and this does not move. A bad fortnight after a bad event is ordinary. The thing to notice is how little the mood shifts, more than how low it goes.

• Flat. Food is fine and nothing tastes of much.
• Sunday. A thing to get through.
• Laughter. You laugh at something funny and feel nothing afterwards.
• The narrowing. First the optional things go, then the social ones, then anything that is not strictly required.
• What is left. Work and sleep, which from the outside looks like a serious person with a demanding job.
• Tired or flat. Tiredness affects what you are able to do. Depression affects what you want.

How do you change high functioning depression?

You stop using your output as the test, and you start sustained work on what the functioning is for.

• One line a day. For 7 days, write one line each evening: what, today, did I want to do instead of have to do?
• Read the blanks. A week of blanks is the clearest information you will get.
• Count the cost. Ask how much of what you have goes into holding the surface steady, and how much is left.
• Say it to one person. The first honest sentence is the hardest one, and it is short.
• Expect sustained work. A meta-analysis of psychotherapy for chronic depression and dysthymia found a small effect for therapy, and a larger effect with more sessions.
• Start before you are forced. Coping is no qualification you have to lose first.

In therapy I work on what the functioning protects, what you believe would happen if you stopped, and what it would take to want something again.

These steps fail when the flatness is the one judging whether this is bad enough to count. That is what the session is for.

Questions people ask

Is it possible to have depression and still function normally?

Yes, because nothing in the clinical definition requires your life to have stopped. Many people keep working, because work is the last thing they let go of.

Is high functioning depression an official diagnosis?

High functioning depression is an informal description and no formal diagnosis. For depression lasting at least 2 years, the clinical term is persistent depressive disorder.

How do I know if I am depressed or just tired?

Tiredness lifts when you rest, and flatness does not. A free weekend with nothing required of you leaves the flatness where it was.

Does therapy work for depression that has lasted years?

Therapy helps, and the research shows it works through sustained sessions more than through a short course.

What does therapy work on here?

Therapy works on what the functioning is protecting and what you believe would happen if you stopped. That is slower than symptom relief.

Sources

• Cleveland Clinic, What is high-functioning depression? Signs and symptoms
• World Health Organization, Depressive disorder (depression), fact sheet
• Nübel, Guhn, Müllender, Le, Cohrdes and Köhler, Persistent depressive disorder across the adult lifespan: results from clinical and population-based surveys in Germany, BMC Psychiatry, 2020
• Cuijpers, van Straten, Schuurmans, van Oppen, Hollon and Andersson, Psychotherapy for chronic major depression and dysthymia: a meta-analysis, Clinical Psychology Review, 2009

How this article was written. I choose the subject and the angle. An AI assistant researches and drafts. Nothing is published until I have read it, corrected it and stood behind every clinical statement in it. The professional and clinical judgement is mine and mine alone.