Is High-Functioning Depression Real?

High-functioning depression is real, and there is an actual name for it: persistent depressive disorder (PDD).

This mental illness is particularly insidious, because for all intents and purposes a person with it is doing fine. They function well enough at work, at home, and at school, and to anyone observing they seem to be healthy, if a little gloomy.

The truth is that on the inside, someone with this milder type of depression is struggling.

They may feel empty and numb, sad, down on themselves, and as if they are just hanging on, but treating this condition is possible and effective.

Mental illnesses like depression often cause people to have impaired functioning. The degree to which an illness impairs a person’s ability to function in their everyday lives depends on the specific illness, the severity of the symptoms, whether the person is receiving adequate treatment, and many other individualized factors.

Conditions like depression can impair functioning in a variety of ways. For example, feelings of depression, low self-esteem, and fatigue can cause a person to avoid social functions or may cause problems in existing relationships. Other ways in which mental illness may impair functioning include causing missed days at work or school, poor performance at work or school, an inability to complete normal responsibilities, and even an inability to do very basic things like maintaining personal hygiene.

When someone is described as high-functioning it means that he or she manages to do all those things, like going to work, maintaining relationships, and keeping up with responsibilities, while living with a mental illness or symptoms of a mental illness. On the outside, this person may seem as if there is nothing wrong, like they feel fine, but internally they may be struggling, feeling numb or sad or tired.

When mental health professionals screen patients for their ability to function, they look at several areas: autonomy, or the ability to care for oneself, being able to keep a job and do it well, mental functioning, which includes memory and decision-making, financial well-being, relationships, and leisure time. Someone may score high enough in these areas but still be struggling with mental health issues.

Depression is a feeling and a mood that all people experience sometimes, but it is also a diagnosable mood disorder and a category of related mental illnesses. As a diagnosable mental illness, depression is a serious condition that causes moderate to severe symptoms that persist and do not get better without treatment. The characteristic symptoms of depression are:

• Feelings of depression and sadness
• Loss of interest in typical, and once enjoyable, activities
• Loss of appetite or overeating
• Insomnia or oversleeping
• Fatigue and lethargy
• Trouble thinking, concentrating, remembering, or making decisions
• Feeling guilty or ashamed
• Unusual affect, which may be decreased and flat or agitated and angry
• Suicidal thoughts and behaviors

There are also different types of depression. Bipolar depression is accompanied by periods of mania. Postpartum depression occurs in women after childbirth. Premenstrual dysphoric disorder is severe premenstrual syndrome that includes depression. Seasonal affective disorder causes depression in the fall and winter. There is also a type of depression called persistent depressive disorder, which causes milder symptoms of depression that allow most people who have it to be high-functioning.

Also known as dysthymia and high-functioning depression, PDD is a type of depression that causes less severe symptoms than major depression. About 1.5 percent of the population struggles with PDD every year, but less than two-thirds of those people get any treatment for it. The average age for PDD to begin is 31, although everyone is different, and signs of high-functioning depression may begin at any age.

PDD is a chronic type of depression that can last for years. It causes many of the same symptoms of depression, like hopelessness, sadness, loss of interest in activities, and fatigue, but they are usually milder. While PDD is generally less severe than major depression, it can cause episodes of symptoms that are moderate or even severe. PDD persists and causes symptoms on most days for a period of at least two years.

This is the type of depression that is often referred to as high-functioning, because with the milder symptoms someone with PDD is often better able to function in their daily lives than someone with major depression. A person with PDD may seem to others to be generally gloomy or lacking in energy, but they can usually hold down a job, do well enough in school, and manage healthy relationships, or in other words function at a normal level. But, these individuals are simply going through the motions much of the time and not getting much enjoyment out of life.

The only way to know for certain if you have PDD, or high-functioning depression, is to be evaluated by a mental health professional. That professional will evaluate you through observations and interviews, as well as by examining your medical record or physical health, to determine if you meet the criteria for a diagnosis. PDD is listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as a type of depression. A person must have two or more of the following symptoms most days for at least two years to be diagnosed:

• A sense of hopelessness
• Difficulty concentrating, thinking, and making decisions
• Low self-esteem
• Fatigue or lethargy
• Changes in sleep patterns, either sleeping more or less
• Changes in appetite, either loss of appetite or overeating

There are other criteria as well. For instance, a person must not experience relief from the symptoms for longer than two months during the two-year period. There cannot be any episodes of hypomania or mania, which would indicate bipolar disorder. The symptoms cannot be caused by another mental illness, substance use, or a medical condition. And finally, to be diagnosed with this condition, the symptoms must cause significant impairment or distress.

Just because a person with PDD is able to function to a degree that is considered normal or that is similar to how the person functioned before developing the condition does not mean that he or she cannot benefit from treatment. In fact, people with high-functioning depression should get treatment. Through treatment they can learn to change negative thought patterns, learn coping strategies, and benefit from medications to improve mood and overall enjoyment of life.

Treatment for PDD includes two main strategies: therapy and medications. Antidepressant medications can provide relief from feelings of depression and low mood, but it takes time for them to work and sometimes more than one medication to find the one that has the best impact with the fewest side effects. Medication is not enough to treat high-functioning depression and should be used in conjunction with therapy.

A stay in a residential treatment facility can help an individual really focus on behavioral therapies and learning ways to cope with and change the negative thoughts caused by PDD. This kind of treatment allows a person to take the time to learn the skills needed to be more successful outside of treatment. Patients in residential therapy programs develop strategies, skills, and tools that they can then use later to live well with this condition.

Therapy and residential care teaches patients how to live better with PDD. Like other mental illnesses, this is a chronic condition that may recur throughout a person’s life. But using skills learned in therapy and making lifestyle changes at home can help an individual avoid or minimize relapses while also getting more out of life. Important strategies to use after treatment include:

• Continuing with regular therapy sessions or group support as needed
• Communicating with a doctor regularly about antidepressant use, as effectiveness can change over time
• Recognizing triggers and learning how to cope with situations that cause depressed moods
• Making self-care a priority, including eating well, sleeping adequately, and getting regular exercise
• Avoiding drugs and alcohol
• Engaging with others and making time to socialize

High-functioning depression is very hard to see from the outside. A person may seem perfectly fine but be struggling on the inside. If you know someone who is experiencing depression but still functions well, offer support and help. Encourage that friend or family member to speak to their doctor or a mental health professional about being screened for depression. While PDD may not seem that serious, it can be, and someone who is high-functioning but not treated may see periods of worsening symptoms. Be a good, non-judgmental listener, a supportive friend, and encourage your friend to get help.

Living with high-functioning depression is just going through the motions— surviving. It is not a good way to live, even if externally it seems as if someone with this condition is doing fine. If you or someone you know is struggling with mild but persistent symptoms of depression, reach out to offer or get help. Treatment is effective for managing this condition.