High functioning depression: What it is and how to deal with it

Do you feel like…

You are smiling on the outside and screaming on the inside?

Day-to-day you fulfill all your responsibilities despite the challenges, so everyone thinks you are fine but you’re not?

Your invisible illness means others don’t understand you, and it is difficult for you to ask for the help you need?

Recent government statistics show that about 7% of adults in the U.S. (or 17.3 million people) reported having at least one significant episode of depression.

Women appear to be more depressed than men (8.7% as opposed to 5.3%).

The most depression occurs in the age group 18-25.

So, it’s not something you are making up, nor are you the only one with this illness.

Fortunately, we know a lot about high-functioning depression, including how to treat it.

So, check what you know about this condition, and then read about how best to deal with it

Quiz Time: True or False

How much do you know about the differences between Depression [Major Depressive Disorder (MDD)] and High-functioning Depression [Dysthymia or Persistent Depressive Disorder (PDD)]?

To find out, decide if these statements are true or false.

1. Depression (MDD) lasts for years but High-functioning Depression (PDD) comes and goes.

False, it is actually the other way around.

When people with MDD are not in a period of depression, their mood measures as normal on the medical scale.

On the contrary, those with PDD are always depressed and cannot remember the last time they weren’t.

In general, MDD is diagnosed after only two weeks of symptoms while PDD is only diagnosed after two years.

(source for all above)

2. High-functioning Depression (PDD) is debilitating. In other words, people with PDD cannot keep to their usual routines.

False (again), and this is one of the most important differences.

Those suffering from Major Depressive Disorder are what we usually think of when we think of classic ‘depression’.

You know, those people who can’t get out of bed or hold down a job; who lose interest in life; who are sad and hopeless; who have no motivation or energy.

The really difficult thing is that people suffering from high-functioning depression have all of those symptoms BUT to a lesser degree (at lower levels).

This allows them to mask their depression, and that is the heartbreaking thing about this condition.

People with PDD are usually able to go about their regular routines, yet they are crumbling and hurting inside.

High-functioning depressives go to work, take care of their families, keep up their homes—in short, do the things that everyone else does.

However, each activity is an exhausting struggle. In other words, the storm inside is hidden by the calm outside. 

3. A person can have either Depression (MDD) or Dysthymia (PDD) but not both.

For a three for three, this one is ‘false also.

A person can struggle with PDD for many years and then suddenly have a major MDD episode.

This is known as ‘double depression’.

Just to recap…

High-functioning depression (PDD) does not stop people from living ‘regular’ lives. 

The levels (amounts) of the symptoms are not high enough to prevent people from keeping to their usual routines.

This is why it is such a difficult illness.

Difficulty #1

Since it is hidden (and the person is acting as usual), family, friends, and colleagues of PDD sufferers may not know they are depressed.

As a result, others may not believe people with high-functioning depression when they ask for support. 

It is important to remember that just because an illness doesn’t have symptoms you can see doesn’t mean it isn’t real.

Difficulty #2

The Dysthymia (PDD) sufferers themselves may not take their condition seriously enough.

After all, they are doing everything they need to do, right?

High-functioning depression is a mental disorder. Many people would feel shame to have such a condition.

As a result, they may not give themselves permission to cope with their depression. They may not seek treatment.  

The most powerful way to deal with high-functioning depression is to ask for (and accept) help.

The following options are not an ‘either – or’ type of thing. Studies support the idea that a combination approach appears to be the most effective.

For example, one study found that even after 9 years, roughly 50% of the patients treated with a combination approach were still coping excellently with their high-functioning depression.

When asked, the patients explained that they had succeeded because they had received “tools to handle life”. 

1. Develop a support network

This option requires you to be very brave.

It will take bravery to admit to your family, friends, and colleagues that you have a ‘mental illness/condition’.

Even though the general public is much more familiar and accepting of mental issues, there are still some who will see you as ‘crazy’.

The research shows that this investment of your bravery can have huge returns because a support network is one of the most helpful things for those with high-functioning depression.

Here are suggestions for how to develop one:

I. Educate your people

In this case, you are the expert of you. So, you’ll need to explain to your people how high-functioning depression plays out for you.

Sure, they can read lots of good information on the internet, but every case is different.

Only you know the ins and outs of your particular situation.

Be specific. Give them concrete examples of what happens, how you feel, how you behave, any known triggers, etc.

The more specific you can be, the better your support network will be able to identify critical times and help you out.

II. Offer a list of dos and don’ts

Take some time to think about what you want them to do…and what you DON’T.

Here are some examples:

  • Accept and validate my description of what’s going on with me at the moment.
  • Don’t judge or make statements such as, “How could you feel that way? Your life is so great.”
  • Realize that my situation has nothing to do with you. 
  • Don’t ask, “What can I do?” Instead, make a specific offer such as, “Do you need a ride to the doctor? Would you like to go for a walk in nature? Want to hit the gym?”
  • Love me with small acts of kindness. For example, take my dog for a walk when I am feeling overwhelmed, stop by with a casserole, give me a 15-minute shoulder rub.

III. Use your support network

Remember we spoke earlier about giving yourself permission to cope with your illness?

Here it is again…only in a bigger way. Ready?

Put your pride aside. Lay down your masks, and open your barriers.

Think of it this way…if your friend needs glasses, shouldn’t they get their eyes examined and buy a pair?

If your family member has a serious infection, shouldn’t they see a doctor and get some medicine?

Medical science doesn’t know exactly what causes depression. However, it is generally accepted that a significant part relates to brain chemicals—things like chemical imbalances, neurotransmitter issues, poor brain regulation of mood, etc.

This means that while high-functioning depression is likely all in your head, it isn’t really—if you know what I mean.

Bottom line? You have a real illness (or condition). Thus, you deserve all the treatment, help, and support available.

Just as it is not shameful to wear glasses or take antibiotics, is it not shameful to get help for high-functioning depression.

It is actually very brave, very brave indeed. 

2. See a therapist

The data shows that the type of therapy used to treat high-functioning depression does not seem to be so important. The reason is that many of the therapeutic principles overlap.

At the moment, there are several main ‘go-tos’.

Cognitive Behavioral Therapy (CBT): CBT is a practical approach. Basically, the idea is when you change your thought or behavior patterns, you change your feelings.

One of the specific CBT skills is behavioral activation—learning exactly how your behaviors affect your emotions.

Behavioral activation can be used on its own or as part of a more complex CBT therapy program.

Interpersonal Therapy: As its name suggests, interpersonal therapy is based on the theory that our personal relationships are the roots of our problems. When we clear up our ‘people issues’, our physical symptoms such as high-functioning depression get cleared up as well.

Cognitive-Behavioral Analysis System of Psychotherapy (CBASP): This therapy type integrates the methods of cognitive, behavioral, interpersonal, and psychodynamic therapies into one approach.

CBASP is a relatively new approach, but the data appears to show that this combined effort is more effective than any of the individual therapies alone.

3. Take an antidepressant

Choice #1: SSRIs

The first choice of many health practitioners is one of the selective serotonin reuptake inhibitors (SSRIs)

The reason is because this group of medications appears to be most effective and most easily tolerated. 

How they work

Serotonin is known as the ‘feel-good’ neurotransmitter (brain chemical messenger) because it gives us a calm sense of well-being.

Research shows that depression is often linked to low levels of serotonin in the brain.

SSRIs stop the brain from absorbing the amount of serotonin it usually does.

The result? More serotonin in the brain makes you feel less depressed.

Who they are

Names change but at the moment, you might have heard of popular options such as Prozac and Zoloft.

Choice #2: SNRIs

Next in line are the serotonin-norepinephrine reuptake inhibitors (SNRIs).

How they work

These dual-acting antidepressants work on serotonin (see above) and norepinephrine—a different neurotransmitter which helps keep us energized and alert.

SNRIs improve the levels of BOTH serotonin and norepinephrine in your brain.

The result? You feel less depressed, more energetic, and more alert.

Who they are

Currently, names you may be familiar with are Fetzima, Khedezla, and Pristiq.

Another option: TCAs

Tricyclic antidepressants (TCAs) became available in the 1950s and were one of the first options on the market.

Although ‘old’, they are still considered useful for people whose high-functioning depression is not helped by the other options.

However, some of their side effects can be hard to cope with. As a result, TCAs are not the first choice in most cases.

How they work

Like SNRIs, TCAs also keep more serotonin and norepinephrine floating around in your brain.

As we mentioned above, this tends to improve your mood.

Who they are

Familiar TCAs include Norpramin, Pamelor, Tofranil, and Vivactil.

NOTE: The majority of antidepressants have negative side effects.

It is important to get good advice from your health practitioner before deciding whether taking an antidepressant is the right decision for you.

You will need to weigh the two sides of the coin: the negative effects of your high-functioning depression vs. the possible negative side effects of the treatment.

4. Try alternative treatments

You have symptoms of high-functioning depression. 

In the short term, which do you think will be a more effective treatment: ½ hour of exercise three times a week or drug therapy?

Are you surprised to find out that both options are equally effective? (And exercise has a much lower risk of negative side effects.)

What about the long term?

Perhaps even more surprising is that this exercise plan is MORE EFFECTIVE.

In a study at Duke University, researchers divided their subjects into three groups: drug therapy only, exercise only, and both drugs and exercise.

Here’s what the data showed: 

    • Depression came back for 38 percent of those who were treated with drugs only.
    • Of those who had drugs and exercise, 31 percent had depression return.


  • However, the exercise only group had just an 8 percent depression relapse rate.


(source for all above)

Other alternative treatments include relaxation techniques, yoga, certain types of meditation, and music therapy.

Studies appear to show that these options do not work as well as psychological methods. Yet, they are better than nothing at all and can be very valuable as part of a combined approach.


One important resource is U.S. Department of Health and Human Services: Substance Abuse and Mental Health Services Administration (SAMHSA).

This group runs the national helpline all day, every day. The number is  1-800-662-HELP (4357) and you can speak to someone in English or Spanish.

OK…up for another quiz? Sure you are.

Which of the following statements best sums up high-functioning depression?

#1 It is a long-term illness which is often hidden from the eyes of others. That is because sufferers are usually able to continue with their regular lives despite the huge challenges they must overcome to do so.

#2 A combination approach to therapy is the most effective. This method includes a support network, psychotherapy, and antidepressant medication.

#3 High-functioning depression is a REAL condition. It is not a fantasy or some ‘crazy idea’. Thus, sufferers are entitled to treatment and understanding, the same as with any illness.

So this was a trick question because all the statements are equally correct (but you probably knew that, right?).

If we combine all three, we get a complete and accurate picture of high-functioning depression. 

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Lachlan Brown

I’m Lachlan Brown, the founder, and editor of Hack Spirit. I love writing practical articles that help others live a mindful and better life. I have a graduate degree in Psychology and I’ve spent the last 15 years reading and studying all I can about human psychology and practical ways to hack our mindsets. Check out my latest book on the Hidden Secrets of Buddhism and How it Saved My Life. If you want to get in touch with me, hit me up on Facebook or Twitter.

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